Analysis

Making evidence based medicine work for individual patients

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2452 (Published 16 May 2016) Cite this as: BMJ 2016;353:i2452
  1. Margaret McCartney, general practitioner1,
  2. Julian Treadwell, general practitioner2,
  3. Neal Maskrey, visiting professor3,
  4. Richard Lehman, senior advisory fellow in primary care4
  1. 1Fulton Street Medical Centre, Glasgow G13 1NG, UK
  2. 2Hindon Surgery, Wiltshire, UK
  3. 3School of Pharmacy, Keele University, Staffordshire, UK
  4. 4Cochrane UK, Oxford, UK
  1. Correspondence to: M McCartney margaret{at}margaretmccartney.com

Margaret McCartney and colleagues argue that new models of evidence synthesis and shared decision making are needed to accelerate a move from guideline driven care to individualised care

A Google Scholar search using the term “evidence based medicine” identifies more than 1.8 million papers. Over more than two decades, evidence based medicine has rightfully become part of the fabric of modern clinical practice and has contributed to many advances in healthcare.

But many clinicians and patients have expressed dissatisfaction with the way evidence based medicine has been applied to individuals, especially in primary care.1 There is concern that guidelines intended to reduce variation and improve the quality of care have instead resulted in medicine becoming authoritarian and bureaucratic.2 Evidence generated from large populations has been distilled into large numbers of lengthy and technically complex guidelines. Guidelines in turn have been used to create financial incentive schemes such as the UK’s Quality and Outcomes Framework, whereby a substantial proportion of general practice income depends on achieving thresholds for drug therapy or surrogate outcomes in accordance with National Institute for Health and Care Excellence guidelines. Not only do these thresholds exceed the limits of the evidence for many people but they also encourage clinicians to ignore the need to elicit and respect the preferences and goals of patients.

Guidelines and shared decision making

Guidelines grew out of a need to communicate best current evidence to clinicians, but their limitations are often not explicitly stated (box 1). For example, some guidelines on heart failure adopt an entirely disease oriented approach, ignoring patients’ views about the quality of their remaining life and the need to incorporate their goals in decision making.3 Depression guidelines often fail to acknowledge individual patient circumstances, especially how adverse life events or social support influences symptoms and responses to treatment.4

Box 1: Problems with applying population based evidence to individuals

  • Randomised …

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