Resisting cookbook medicine

BMJ 2004; 329 doi: (Published 15 July 2004) Cite this as: BMJ 2004;329:179
  1. Stephen J Genuis, associate professor,
  2. Shelagh K Genuis (sgenuis{at}, health researcher
  1. University of Alberta, Canada

    “It is now the standard of care that every postmenopausal woman be given replacement hormones for the rest of her life unless there is a medical reason not to; to practise otherwise may be considered malpractice.” These words, passionately spoken at a 2001 medical education conference by a foremost authority on women's health, left some listeners feeling uneasy. Unable to find randomised controlled trials that validated the presumed benefits of long term hormone replacement therapy (HRT), we concluded that HRT for disease prevention represented an experiment on women.

    Today, two years after the release of the results of the women's health initiative study showing that HRT has more potential for harm than for good in healthy postmenopausal women taking a combination of oestrogen and progestogen to prevent chronic disease, the questions of 2001 remain relevant. Do individual doctors have the freedom to critically analyse available evidence and make management decisions that are based on informed reading of the literature and clinical experience? And, as medicine is essentially “work in progress,” how do we foster healthy tension between doctors' autonomy and the “standard of care”?

    The HRT fiasco highlights the progressive role of thoughtful dissent

    Accountability and acceptable standards of practice are prerequisites for self governing professions such as medicine. To try to ensure acceptable standards in an era of rapidly proliferating information and treatments, clinical practice guidelines have increasingly been implemented. While there are benefits to providing specific recommendations to doctors, the routine use of predetermined directives threatens to reduce doctors to practising “cookbook medicine”—thus contributing, perhaps, to increasing disillusionment within the profession, as the art of medicine is slowly eroded by management protocols. Furthermore, medical administrators and experts—including lawyers in search of “lucrative lapses”—are using standardised guidelines as templates to measure doctors' clinical performance.

    Two things need to be borne in mind when considering the influence of experience and informed reading on doctors' decision making: the time lag between medical discovery and clinical implementation, and the documented influence of industry. In his book Helicobacter Pioneers Barry Marshall, one of the doctors who identified the link between H pylori and ulcer disease, reflected on his slow and difficult journey of bringing about change in the medical community: “Was gastroenterology a science or a religion? I decided it was the latter.” Although accepted patterns of practice provide reassurance and stability, it is research based dissonance and openness to exploring new ideas that move medicine forward.

    In 2001, when many people were trumpeting the benefits of HRT, it was troubling to find that there was little evidence supporting the safety of long term HRT; in fact much of the literature suggested concern. So what had catapulted HRT into the limelight to such a degree that it had become a top selling treatment?

    Although the question is complex, the history of involvement of corporate interests in the development and promotion of long term preventive HRT is extensive. While medicine has long had a mutually profitable relationship with industry, this alliance has grown ever more uneasy as an increasing number of individual researchers, faculty members, and even academic institutions have developed close financial ties to companies whose products they are studying. Industry is influencing the research process in other ways: it influences the research questions that are chosen, methodology of studies, data analysis, whether results are published, and dissemination of results. It has even been found that some clinical practice guidelines and statements from “consensus conferences” are being indirectly funded by industry through grants to individuals and to specific foundations.

    As translation of knowledge into clinical practice is often slow, and because medical dogma has been proved wrong on many occasions, it is critical that practitioners retain the freedom to pursue evidence based scientific fact. Balancing doctors' autonomy with care guidelines is thus particularly relevant. Doctors have a responsibility to scrutinise and integrate into practice new information and trends in medical management. Evaluating and using research findings in daily clinical practice is, undoubtedly, a lifelong part of professional development.

    The HRT fiasco eloquently illustrates the potential shortcomings of doctrinaire clinical directives and highlights the progressive role of thoughtful dissent in the evolution of medical thought. Perhaps it is time to re-evaluate the tendency to regard authoritative documents as dogma and time to foster a healthy tension between autonomy and professional standards.

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