Even by the 1990s the reputedly
omniscient senior physician, the dependably avuncular general practitioner,
the handmaiden nurse and the acquiescent patient were already disappearing.
Across the health professions, where the traditional hierarchies were tumbling, new
relationships between professionals were emerging (see, for example, Ashburner
and Birch 1999; Childs 2008) with general practitioners employing increasingly
larger numbers of nurse practitioners and indeed in some rare instances doctors
and nurse practitioners combining on an equal footing to form general practices.
Since then multidisciplinary teams have been increasingly expected to break down
the old pecking order; innovative roles such as nurse practitioners and physicians’
assistants have been blurring professional boundaries. Patients – gradually becoming
relabelled as ‘clients’ by some health professions to stress this very point – seem
often to know a great deal about, and are ever more encouraged to have a strong
say in, how their illnesses are managed. To that end they now have potential access
to rich resources of knowledge and advice not only through patients’ organizations
but through the internet. Clinicians too are faced with many more sources
of knowledge that they need to take account of when practising.
As a result the professions have been described as being ‘under siege’ (Fish
and Coles 1998: 3). As clinical freedom and authority give way to managerialism,
the once autonomous doctor must now comply with bureaucratic norms and
targets or face the consequences (e.g. Ferlie et al. 1996). The clinicians’ employers
might well constrain how they may or may not manage their patients. The shift of
doctors’ status from self-determining professional to regulated employee has even
2 Practice-based Evidence for Healthcare
been described as the ‘proletarianization’ of medicine (e.g. Elston 1991), a term
that certainly reflects the shift of power but underplays the equally important shift
in education, lifelong learning and the status of clinical knowledge.
The training of clinicians has evolved hand in hand with these changes in
their environment. The tradition of undergoing a fixed period of didactic clinical
teaching followed by bedside apprenticeship is being phased out across the healthcare
disciplines in favour of more flexible, self-directed and reflective learning.
New educational principles have been transforming clinical education through
problem-based learning, inter-professional learning, competencies-based training,
ever more rigorously objective examinations, continuous professional development,
clinical audit, appraisal and revalidation. Lifelong learning has replaced the
once-and-for-all qualification. There is increasing stress on delivering and checking
competencies rather than inculcating values and professional wisdom (Fish and
Coles 2005). The job for life is being supplanted by mobile career paths, portfolio
careers and complex private/public partnerships that undermine the traditional
job security of the health professional. Moreover, the specialized knowledge that
clinicians bring to their practice no longer carries the arcane mystique that it once
did. The incontestability of a senior clinician’s individual, autonomous knowledge
has been undermined by the clinical guideline, the systematic review, the organizational
target and the web-based expert system open to all, including patients.
Senior doctors can be challenged by (perhaps brave) members of the clinical team
who have read the latest guidance, or by patients who have had access to alternative
sources of information about their disease, or by healthcare managers whose
paymasters charge them with cajoling if not coercing clinicians to comply with
new, more cost-effective ways of practising. As a result, the old acceptance that
‘we do things this way because distinguished professors tell us we should and it’s
not for the likes of us to question it’ is much harder to sustain. In short, the clinical
knowledge base is being democratized.
And this is just as well, since the old elitism had produced unacceptable variations
in practice, dependent more on the power of opinionated senior doctors
than on any rational review of all the appropriate evidence. Indeed it was that
very problem that provided much of the fuel for both the democratization of
clinical knowledge and the proletarianization of the clinical professions in the first
place. The aim of many of the reforms was precisely to expose and minimize the
clinical misjudgements of a lofty elite; to replace eminence-based practice with
evidence-based practice.
Evidence-based practice (EBP) took root in the medical profession in the 1990s
(Sackett et al. 1997; Gray 1997) paralleled by other healthcare professions (Mulhall
and le May 2004) and like all social movements it has had many forms and interpretations
among friends and detractors alike (Harrison 1998; Timmermans and
Berg 2003; Dopson et al. 2003; Pope 2003; Rycroft-Malone 2006). At its core,
however, the EBP movement, in whatever guise it might appear, has urged clinicians
to use the available research evidence either by finding, appraising and
applying the best evidence themselves or through using evidence-based guidelines
and treatment protocols (Figure 1.1).
Introduction 3
When David Sackett and his colleagues, who spearheaded the movement,
defined evidence-based medicine as ‘the conscientious, explicit and judicious use
of current best evidence in making decisions about the care of individual patients’
(Sackett et al. 1996: 71; Straus and Sackett 1998; Haynes 2002), they were being
more sophisticated than many who joined them to create the EBP bandwagon
(Trinder and Reynolds 2000).2 Sackett and colleagues’ definition recognizes the
importance of clinical judgement when applying the best evidence in any given
set of circumstances. In contrast, however, much of the organizational change
linked to the EBP movement seems to have been about applying research evidence
overzealously and unthinkingly in clinically inappropriate ways. Clinicians find
themselves urged, for example, to apply the results of clinical trials that might have
been carried out in selected minorities of patients who are quite different from the
majority that they themselves treat. Or, worse, they find themselves under pressure
to use clinical guidelines that are not always as explicit as they should be about the
sources and the limitations of the evidence on which they are based (e.g. Grol et al.
1998; Lugtenberg et al. 2009).
EBP has led to a host of reforms across healthcare. They include the mass of
guidelines now available to clinicians, many of which are now prepared to the
very highest standards of evidence and practical relevance, even though – much to
the dismay of those who carefully prepare the guidelines – clinicians are notorious
for ignoring or rejecting them unless they are somehow coaxed or coerced into
using them. EBP has also grown in tandem with the Cochrane Collaboration in
which colleagues from around the world sign up to a lifelong mission to systematically
review all the available research evidence using meticulously controlled and
scrupulous techniques in order to inform best practice in their chosen area.3 This
has been revolutionary not only in the way it has critically collated huge quantities
of research information that was previously ignored, misinterpreted or used
inappropriately, but also in the way it has inspired an almost evangelical fervour
to pursue high-quality evidence and discard bad science (CRAP writing group
2002). Excellent as it is, however, the Cochrane Collaboration still relies heavily on
the randomized controlled trial as the chief arbiter of truth, playing down other
forms of legitimate knowledge and still largely ignoring the social and economic
Focus the question
Search systematically for research evidence
Appraise the relevant evidence for its validity
Seek and incorporate patients’ views
Apply the findings to solve the problem
Evaluate outcome against planned criteria
Figure 1.1 The idealized pathway of evidence-based practice.
4 Practice-based Evidence for Healthcare
aspects of healthcare. Moreover, on close examination the detail often seems to
favour scientific pedantry over the needs of clinical practice. EBP has also fostered
a welcome emphasis on applied health sciences (as characterized, for example, by
the rise of pragmatic and complex trials, of health services research and of health
technology assessment). A parallel development has been the growing industry of
research on the implementation of research, little of which, paradoxically, is widely
implemented.4 Finally, we see the growing influence of the National Institute for
Health and Clinical Excellence (NICE) not only in its native UK, but in countries
the world over that are also experiencing pressures to deliver more cost-effective
care. NICE issues both general guidelines and specific directives about new
treatments; both are rooted in detailed and rigorous assessments of the evidence
on cost-effectiveness. But, like many of NICE’s counterparts that are springing
up around the world, its work is also accompanied by unprecedented levels of
bureaucratization and organizational accountability in healthcare, designed to
encourage if not enforce conformity to ‘best practice’.
omniscient senior physician, the dependably avuncular general practitioner,
the handmaiden nurse and the acquiescent patient were already disappearing.
Across the health professions, where the traditional hierarchies were tumbling, new
relationships between professionals were emerging (see, for example, Ashburner
and Birch 1999; Childs 2008) with general practitioners employing increasingly
larger numbers of nurse practitioners and indeed in some rare instances doctors
and nurse practitioners combining on an equal footing to form general practices.
Since then multidisciplinary teams have been increasingly expected to break down
the old pecking order; innovative roles such as nurse practitioners and physicians’
assistants have been blurring professional boundaries. Patients – gradually becoming
relabelled as ‘clients’ by some health professions to stress this very point – seem
often to know a great deal about, and are ever more encouraged to have a strong
say in, how their illnesses are managed. To that end they now have potential access
to rich resources of knowledge and advice not only through patients’ organizations
but through the internet. Clinicians too are faced with many more sources
of knowledge that they need to take account of when practising.
As a result the professions have been described as being ‘under siege’ (Fish
and Coles 1998: 3). As clinical freedom and authority give way to managerialism,
the once autonomous doctor must now comply with bureaucratic norms and
targets or face the consequences (e.g. Ferlie et al. 1996). The clinicians’ employers
might well constrain how they may or may not manage their patients. The shift of
doctors’ status from self-determining professional to regulated employee has even
2 Practice-based Evidence for Healthcare
been described as the ‘proletarianization’ of medicine (e.g. Elston 1991), a term
that certainly reflects the shift of power but underplays the equally important shift
in education, lifelong learning and the status of clinical knowledge.
The training of clinicians has evolved hand in hand with these changes in
their environment. The tradition of undergoing a fixed period of didactic clinical
teaching followed by bedside apprenticeship is being phased out across the healthcare
disciplines in favour of more flexible, self-directed and reflective learning.
New educational principles have been transforming clinical education through
problem-based learning, inter-professional learning, competencies-based training,
ever more rigorously objective examinations, continuous professional development,
clinical audit, appraisal and revalidation. Lifelong learning has replaced the
once-and-for-all qualification. There is increasing stress on delivering and checking
competencies rather than inculcating values and professional wisdom (Fish and
Coles 2005). The job for life is being supplanted by mobile career paths, portfolio
careers and complex private/public partnerships that undermine the traditional
job security of the health professional. Moreover, the specialized knowledge that
clinicians bring to their practice no longer carries the arcane mystique that it once
did. The incontestability of a senior clinician’s individual, autonomous knowledge
has been undermined by the clinical guideline, the systematic review, the organizational
target and the web-based expert system open to all, including patients.
Senior doctors can be challenged by (perhaps brave) members of the clinical team
who have read the latest guidance, or by patients who have had access to alternative
sources of information about their disease, or by healthcare managers whose
paymasters charge them with cajoling if not coercing clinicians to comply with
new, more cost-effective ways of practising. As a result, the old acceptance that
‘we do things this way because distinguished professors tell us we should and it’s
not for the likes of us to question it’ is much harder to sustain. In short, the clinical
knowledge base is being democratized.
And this is just as well, since the old elitism had produced unacceptable variations
in practice, dependent more on the power of opinionated senior doctors
than on any rational review of all the appropriate evidence. Indeed it was that
very problem that provided much of the fuel for both the democratization of
clinical knowledge and the proletarianization of the clinical professions in the first
place. The aim of many of the reforms was precisely to expose and minimize the
clinical misjudgements of a lofty elite; to replace eminence-based practice with
evidence-based practice.
Evidence-based practice (EBP) took root in the medical profession in the 1990s
(Sackett et al. 1997; Gray 1997) paralleled by other healthcare professions (Mulhall
and le May 2004) and like all social movements it has had many forms and interpretations
among friends and detractors alike (Harrison 1998; Timmermans and
Berg 2003; Dopson et al. 2003; Pope 2003; Rycroft-Malone 2006). At its core,
however, the EBP movement, in whatever guise it might appear, has urged clinicians
to use the available research evidence either by finding, appraising and
applying the best evidence themselves or through using evidence-based guidelines
and treatment protocols (Figure 1.1).
Introduction 3
When David Sackett and his colleagues, who spearheaded the movement,
defined evidence-based medicine as ‘the conscientious, explicit and judicious use
of current best evidence in making decisions about the care of individual patients’
(Sackett et al. 1996: 71; Straus and Sackett 1998; Haynes 2002), they were being
more sophisticated than many who joined them to create the EBP bandwagon
(Trinder and Reynolds 2000).2 Sackett and colleagues’ definition recognizes the
importance of clinical judgement when applying the best evidence in any given
set of circumstances. In contrast, however, much of the organizational change
linked to the EBP movement seems to have been about applying research evidence
overzealously and unthinkingly in clinically inappropriate ways. Clinicians find
themselves urged, for example, to apply the results of clinical trials that might have
been carried out in selected minorities of patients who are quite different from the
majority that they themselves treat. Or, worse, they find themselves under pressure
to use clinical guidelines that are not always as explicit as they should be about the
sources and the limitations of the evidence on which they are based (e.g. Grol et al.
1998; Lugtenberg et al. 2009).
EBP has led to a host of reforms across healthcare. They include the mass of
guidelines now available to clinicians, many of which are now prepared to the
very highest standards of evidence and practical relevance, even though – much to
the dismay of those who carefully prepare the guidelines – clinicians are notorious
for ignoring or rejecting them unless they are somehow coaxed or coerced into
using them. EBP has also grown in tandem with the Cochrane Collaboration in
which colleagues from around the world sign up to a lifelong mission to systematically
review all the available research evidence using meticulously controlled and
scrupulous techniques in order to inform best practice in their chosen area.3 This
has been revolutionary not only in the way it has critically collated huge quantities
of research information that was previously ignored, misinterpreted or used
inappropriately, but also in the way it has inspired an almost evangelical fervour
to pursue high-quality evidence and discard bad science (CRAP writing group
2002). Excellent as it is, however, the Cochrane Collaboration still relies heavily on
the randomized controlled trial as the chief arbiter of truth, playing down other
forms of legitimate knowledge and still largely ignoring the social and economic
Focus the question
Search systematically for research evidence
Appraise the relevant evidence for its validity
Seek and incorporate patients’ views
Apply the findings to solve the problem
Evaluate outcome against planned criteria
Figure 1.1 The idealized pathway of evidence-based practice.
4 Practice-based Evidence for Healthcare
aspects of healthcare. Moreover, on close examination the detail often seems to
favour scientific pedantry over the needs of clinical practice. EBP has also fostered
a welcome emphasis on applied health sciences (as characterized, for example, by
the rise of pragmatic and complex trials, of health services research and of health
technology assessment). A parallel development has been the growing industry of
research on the implementation of research, little of which, paradoxically, is widely
implemented.4 Finally, we see the growing influence of the National Institute for
Health and Clinical Excellence (NICE) not only in its native UK, but in countries
the world over that are also experiencing pressures to deliver more cost-effective
care. NICE issues both general guidelines and specific directives about new
treatments; both are rooted in detailed and rigorous assessments of the evidence
on cost-effectiveness. But, like many of NICE’s counterparts that are springing
up around the world, its work is also accompanied by unprecedented levels of
bureaucratization and organizational accountability in healthcare, designed to
encourage if not enforce conformity to ‘best practice’.
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