Book Book

Evidence-Based Family Medicine

BMJ 1999; 319 doi: (Published 10 July 1999) Cite this as: BMJ 1999;319:131
  1. Tony Dixon, professor of family medicine
  1. University of Hong Kong

    Walter W Rosser, Sharon Shafir

    B C Decker, $50, pp 180

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    ISBN 1 55009 053 4

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    Evidence based care requires the use of the best external evidence in the care of patients, usually derived from studies of populations of patients and mostly disease oriented and quantitative in nature. Patient centred care, in contrast, emphasises concerns about illness rather than disease and incorporates qualitative data about the concerns and beliefs of individual patients.

    Shared decision making, when patients as well as doctors have access to the relevant information, and in which the patients' values and preferences play an important role, is a way of bridging the gap between these two viewpoints. For it to be successful, however, doctors must be able to assess the information in the first place, as well as the skill to present it to their patients in an informative and balanced fashion. In this book the authors attempt to tackle both these challenges, with mixed success.

    The first half of the book consists of 13 brief chapters that provide an overview of how to read and assess the medical literature, particularly as it relates to primary care. Very much in the style of the original series of articles from McMaster University that first unleashed evidence based medicine on an unsuspecting world, the sections are clearly written, easy to read, and provide examples specifically from primary care. For the novice, this section provides an easily digestible introduction to the topic.

    The second half is rather more problematic. In it the authors propose to link evidence based and patient centred care by means of “physician-patient partnership papers.” The task of the “physician partner” is to outline the benefits or risks of a particular test or treatment and to present it in the form of a summary. The “patient partner” and his or her family are encouraged to read the summary and record their own feelings and beliefs about the presented evidence. A decision is then negotiated and recorded in the partnership paper, and both doctor and patient keep a copy of the plan. An abbreviated review of the current evidence in 26 common family practice situations is provided, each with its own partnership paper for both parties to complete once a decision has been reached.

    In some situations the current evidence can be usefully summarised in a page or so, but in others it is considerably more difficult. Hormone replacement therapy, the treatment of hypertension, and screening for cancer, for example, do not easily lend themselves to blanket recommendations for or against. Equally, the way in which the information is presented is at least as important as the information itself. A patient with mild hypertension might well agree to treatment on the basis that it reduces the risk of stroke, but might be less enthusiastic if told that for one patient to benefit, 128 people would need to be treated for five and a half years.

    Even if both physician and patient come to a consensus that, to use examples from the book, the patient does not need a random blood sugar measurement, should not to take an aspirin daily, or ought to use acetaminophen rather than non-steroidal anti-inflammatory drugs for osteoarthritis, do those decisions really need to be formally recorded in the form of a plan endorsed by the patient and family and held by both doctor and patient?

    Overall, the authors provides a useful introduction to evidence based medicine in primary care and a helpful overview of the current evidence in several important family practice situations. Their attempts to combine evidence and patient centred care, while worthy, are less successful, and the physician-patient partnership papers seem as unwieldy as their name.


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