Most of us are familiar with the idea of evidence based medicine (EBM), and the resulting slew of guidelines and care pathways that has become its unavoidable spouse. The unhappy marriage of the high minded ambitions of EBM and the bloated, lifeless prose of protocols does more than offend our literary sensibilities; it points to a harder problem in trying to implement the evidence in EBM. At root, this is a failure to grasp that just as there is evidence in EBM, there must also be evidence about EBM and its applications.
Figure 1.
Eds Sue Dopson, Louise Fitzgerald
Oxford University Press, £45, pp 240 ISBN 0 19 9259011
Rating: ★★★★
Anyone with even a passing interest in how and why changes in health care succeed, or fail, could do far worse than take a look at this book. Based on more than 50 studies of attempts to implement evidence based health care in different NHS settings, it provides a comprehensive and thoughtful review of the evidence about using the evidence in EBM. The picture it paints—of a fragmented set of professionals, often with different priorities and interpretations of the evidence—will be familiar to anyone who has sat through any hospital or practice meeting.
The book, thankfully, avoids the usual bickering by starting with a (lightly treated) theoretical understanding of what it is that people disagree about when they dispute the importance of some new study or guideline, and sidesteps impenetrable theorising by staying close to the subject matter. Some of the material may be familiar to a few readers, but for most of us, interested in why no one else agrees with our (clearly right) opinion on some treatment or guideline, it represents a breath of fresh air and contains lessons for those both producing and implementing the evidence in EBM.
Its rejection of a simple positivist stance towards evidence is its greatest strength (I couldn't find a single p value in the whole book) and, at the same time, points to a subtle book hidden inside this one; at no point do the authors ever explicitly ask what it is that we mean by the term “evidence,” and yet an exploration of the conflicting definitions that hide behind the word might help explain some of the problems that appear when implementing it. However, since a reasonable treatment of this problem would take a book in its own right, this is less a criticism of the book than a request for another one.
This book is for anyone who is interested in why people don't agree on the evidence, and how to try to achieve some common ground for the good of patients. Although written as an academic book, its readability and numerous case studies allow it to drift close to being a “how to” manual for implementing EBM.