Medicine And Books

Evidence-based health care

BMJ 1997; 314 doi: (Published 22 February 1997) Cite this as: BMJ 1997;314:615
  1. Liam J Donaldson, professor of applied epidemiology
  1. University of Newcastle upon Tyne

    J A Muir Gray Churchill Livingstone, £16.95, pp 270 ISBN 0 443 05721 4

    Chekhov once observed that a good writer helps us to feel not just life as it is, but life as it should be. The movement for evidence based medicine offers something similar- enlightenment coupled with views of a promised land. While the conflict between these two states-as it is, and as it should be-is the vehicle for many successful works of art, its force in scientific revolutions is often more divisive. Thus, while evidence based medicine has a large groundswell of support within the profession, it also has many detractors who prefer the status quo.

    In Muir Gray's book the evidence based philosophy is widened to health care as a whole. It is concerned with groups of patients and populations rather than individuals. The target audience is managers, policy makers, and health professionals in management. Ironically, it could be easier to gain their acceptance for the concept: management in health care is a young discipline without the trappings and traditions of medicine. Is it, though, more of an art than a science? Resistance to change may be less, but the increased rigour required could be much greater. Furthermore, in management and policy making the anatomy of a decision is very different from a clinical intervention. Deciding whether to invest in a further cardiothoracic centre in a health region or to move five vascular surgical units to one site, even if evidence were available, is a complex process. It can involve managers, professionals, local interest groups, politicians, the media, and the public. At times, social systems will undermine the science. For example, how often have we seen a decision changed late in the day by a bravura performance in committee, based on emotion?


    The lax skin of Ehlers-Danlos syndrome is easily injured and heals poorly. From the second edition of Ronald Marks's Practical Problems in Dermatology (Martin Dunitz, £25, ISBN 1 85317 050 X), which consists of short sharp chapters on all the common problems and a few rarer ones.

    The book addresses these complex issues very well. It is unusual in being a creative work and a work of scholarship. It is a dazzling mixture of formal definitions, concepts, guiding principles, cautionary tales, frameworks for analysis, checklists for action, and home truths. The presentation of the material is equally eclectic. Case studies sit alongside conceptual diagrams. Illustrative quotations range from a snippet of conversation between Arthur Dent and Ford Prefect (from the Hitch Hiker's Guide to the Galaxy) to words of wisdom from the late Archie Cochrane (Effectiveness and Efficiency). Viewpoints in case histories range from that of a walnut between nutcrackers to that of an eminent surgeon with cancer. “Dear Reader,” introductions prompt each new concept in a style somewhere between agony aunt and Aesop's fables.

    Policy making and management in health care badly need their own evidence based movement. This needs champions, concepts and methods, and an infrastructure in training and information management. This excellent book is an important start.

    Rating: ****

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