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Book Review
Evidence-Based Medicine and the Search for a Science of Clinical Care
Jeanne Daly
ISBN: 0-520243-16-1 2005 276 pages University of California Press
Steffan Timmermans
Jeanne Daly documents how evidence-based medicine turned from a subversive set of ideas of single-minded people across the globe, into the latest buzzword in clinical science. In contemporary health care, to be against evidence-based medicine is to be against science, progress, and rationality. Evidence-based medicine stands for practicing medicine with a scientific basis. Medical decision-making should be guided by the best available, carefully evaluated quantitative evidence rather than by the experiences of medical authorities. For supporters, evidence-based medicine is the answer to incompetent physicians, clinicians overwhelmed by an endless stream of research articles, lack of efficient interventions, practice variation, cost-overruns, lingering clinical uncertainties, stale medical education, and health care inequities. For critics, evidence-based medicine ‘rips the heart out of medicine' to replace it with an algorithm. Evidence-based medicine, critics further argue, is insufficiently clinical, methodological myopic, and leads to mindless standardisation. Still, in one generation the critics have been put in a defensive position, forced to explain that with all the problems in health care why wouldn't better science improve results.
Daly offers the history of evidence-based medicine and clinical epidemiology based on, what can be described methodologically as, intellectual network studies. The core of her book consists of in-depth interviews with leading evidence-based figures in Canada, United States, Britain and South Africa who comprise an international network of like-minded thinkers. She introduces a figure with a short characterisation (eg ‘The Internationalist: Kerr White' 2005:40), and then sums in a couple of pages the person's career path and achievements based on their published record and interview data.
So, how do you become a leading figure in evidence-based medicine? You are a male clinician trained in the sixties. You are deeply frustrated with what you consider wrong-footed medicine, and you question the authority of your teachers. You decide to discover the ‘true science' behind medical interventions. You become a strong believer in the randomised clinical trial or in meta-analyses of clinical trials. You do some studies. Besides strong research credentials, you also have a knack for convincing your initially sceptical colleagues. Soon, you are spreading the evidence-based medicine gospel through education, databanks, textbooks, and institutes. You have become mainstream medicine. You ignore those who question your authority. All around the world, the career paths seem remarkably similar.
Among the pioneers, the most effective advocate of evidence-based medicine is the charismatic David Sackett. At McMaster University in Canada, Oxford University in Britain, and in hundreds of talks, he links scientific evidence to the bedside. Sackett has a talent for inspiring colleagues to ignore established dogma, drawing in talents foreign to medicine, and building institutions. Sackett was inspired by Alvan Feinstein who had challenged medicine with a broad intellectual, research-based agenda to turn the clock back to a time of diagnostic taxonomies of clinical symptoms, relying on better medical technologies and quantitative principles. Another dominant figure was Archie Cochrane who made the case for randomised clinical trials as a way to eradicate bias in research studies. His name is connected with the preeminent institute of evidence-based medicine, the Cochrane Collaboration, which consists of research groups all over the world voluntarily summarising and updating medical know-how.
Evidence-based medicine promised a scientific revolution but did it actually deliver? There is no doubt that evidence-based medicine has changed the health care field over the past decades. Medical students are now taught evidence-based curricula; professional organisations create and disseminate evidence-based guidelines; the randomised clinical trial is the ultimate authority of medical knowledge; and journals regularly publish meta-analyses about clinical topics. We know more about which interventions are likely to work thanks to the critical scrutiny of evidence-based medicine advocates. But, what is evidence-based medicine's effect at the bedside? The ultimate aim of evidence-based medicine is to render clinicians, in Cochrane's words, more efficient and effective. Here, as Daly explains in the last chapters, the record is disappointing: there seems greater sensitivity and awareness of epidemiological methodologies in medicine but most of the thousands of meta-analyses and clinical practice guidelines produced by evidence-based medicine advocates have a marginal effect on clinical decision-making. Clinicians simply ignore the carefully evaluated and ranked research literature: there is a fifty-percent chance that your physician will provide care that conforms to the current best evidence available. Where it really matters, evidence-based medicine has thus largely failed.
Daly seems overwhelmed by the nebulous field of evidence-based medicine and the strong opinions of her research subjects: her book lacks a thematic argument or central logic to tie the data together. She threads timidly where a strong analytical vision seems more appropriate. She foregoes opportunities to explore interesting themes such as the tension between art and science in medicine, the conflict between medicine and public and community health, the problem of uncertainty in practicing medicine, the rise of quantification in seemingly non-quantitative areas, and the dissemination of ideas. The book reads as a collection of biographical ‘who is who' vignettes, connected by chance meetings at conferences or student-teacher encounters. Everyone receives fifteen minutes (or 2-5 pages) of fame but few contributions are emphasised or contextualised. The study is multinational, but little comparatively is done with the materials. Daly also ignores the clinical side of medicine. Evidence-based medicine is foremost about rendering better clinical care, but Daly does not inform readers what has actually been happening at the bedside. Instead she reviews some studies dealing with clinical problems and points repeatedly to a lack of community and public health focus. Critics of evidence-based medicine thus have their suspicion confirmed that evidence-based medicine is insufficiently clinical. The lack of persuasive thematic direction in Daly's book is a pity because evidence-based medicine merits a strong historical analysis not distracted by colorful personalities but concerned with how this well-intentioned movement, aimed, and, perhaps, failed, to address real problems in health care.
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