Evidence based medicine: does it make a difference?

Editor—Gabbay and le May put into focus the processes of “collective sense making” by which knowledge, both explicit and tacit and from whatever sources, is negotiated, constructed, and internalised in routine practice.¹ They identified mindlines replacing guidelines in daily practice. If these processes of collective sense making are assumed to be shaped by, among other factors, culture and training, I wonder whether the social construct of mindlines is also a valid approximation for other countries.

For Germany I think that a similar study would reveal neither mindlines nor other linear structures. Instead of the linear, algorithm driven process commonly used in Anglo-Saxon practice, in Germany the process of diagnosis might better be described as adjusting memorised disease patterns to the clinical pictures of patients. The experience of a doctor is reflected by an increased number of actively retrievable disease patterns. The linguistic equivalent would be the term Krankheitsbild, “disease image” rather than “clinical picture,” thought of as representing the essential character of a disease rather than the mere symptoms. Krankheitsbilder are structuring lecture series for medical students and seem to shape the structure that underlies clinical thinking in Germany.

To overcome the deep rooted resistance against evidence based medicine in Germany, clinical practice would need to win minds and hearts. A first step would be accepting that the predominant processes of collective sense making—namely, adjusting disease patterns with clinical pictures—might not be fully compatible with following linear algorithm oriented guidelines.