Campaign is launched to make patients the focus of evidence based medicine

Doctors’ social functions have been replaced by templates and algorithms, leaving patients sidelined and overtreated, one of the architects of a new movement to put patients at the centre of evidence based medicine has said.

Clinical care has become “medicalised and bureaucratised,” said Trish Greenhalgh at the launch of the Campaign for Real EBM on 3 July at a conference organised by BioMed Central on health services research. Greenhalgh is professor of primary healthcare and dean for research impact at Queen Mary college, University of London.

Greenhalgh acknowledged the “huge importance” of evidence based guidelines. Incentivising GPs to identify and treat undiagnosed hypertension through the NHS’s Quality and Outcomes Framework (QOF) for primary care had served to prevent countless strokes, she said. “But add 150 more [targets] and you have taken that really good idea and killed the reactive care,” she said.

In a recent paper in The BMJ Greenhalgh and colleagues set out the background to the campaign and described what had gone wrong with evidence based medicine.1 Problems included the misappropriation of the “evidence based kitemark” by people with conflicts of interest; the ever increasing and unmanageable volumes of evidence; the patient’s voice going unheard because of the “managerialisation” of medicine; and the poor fit of guidelines with the growing number of people with multimorbidity.

The paper described one case of a “74 year old who is put on a high dose statin because the clinician applies a fragment of a guideline uncritically and who, as a result, develops muscle pains that interfere with her hobbies and ability to exercise.” This was, the authors said, “a good example of the evidence based tail wagging the clinical dog. In such scenarios, the focus of clinical care shifts insidiously from the patient (this 74 year old woman) to the population subgroup (women aged 70 to 75) and from ends (what is the goal of investigation or treatment in this patient?) to means (how can we ensure that everyone in a defined denominator population is taking statins?).”

They said the case illustrated how “evidence based medicine has drifted in recent years from investigating and managing established disease to detecting and intervening in non-diseases. Risk assessment using ‘evidence based’ scores and algorithms (for heart disease, diabetes, cancer, and osteoporosis, for example) now occurs on an industrial scale, with scant attention to the opportunity costs or unintended human and financial consequences.”

At the campaign launch Greenhalgh said, “If patients knew how much of their consultation was driven by box ticking they would be hopping mad. We need more research about how to make the doctor listen to the patient. That needs to be the highest priority.” She added that an estimated 60% of consultation time was spent box ticking.

QOF should be scaled back “massively,” she said, although she admitted that it would be difficult to decide how that would happen.

Greenhalgh said, “Currently, when someone visits their GP or a hospital doctor, quite a bit of the encounter will typically be taken up by the doctor working through a structured computer template that directs the questions to be asked, the parts of the body to be examined, and the recommended medication. In the future, we want to be in a situation where doctor and patient collaboratively set the agenda and share decision making in a more emergent way, guided and supported by tools that both reflect best research evidence—how the average patient is likely to respond to the different treatment options—and also prompt discussion about what matters to this patient.”

She believed that applying evidence based medicine that mattered to patients would save money. “There are lots of interventions that could or might be effective but which people do not want,” she said.