The Best Available Evidence Does Not Dictate How Medicine is Practiced. In other words, the average patient does not dictate a rule, a protocol or a practice standard.
- "include a prioritized checklist of important interventions with the greatest evidence for benefit to patients at the lowest risks and costs."
- "with implementation scientists, [they] could help clinicians identify and mitigate barriers to guideline use and share successful implementation strategies."
- "collaborate to integrate guidelines for conditions that commonly coexist. ...However, these checklists have not been collated and integrated into a care plan or daily workflow to reliably ensure delivery of the practices."
- "rely on systems, rather than the actions of individual clinicians, to ensure patients receive recommended therapies.....the ecosystem will be [enhanced by] software applications, written on an interface platform, linking the EMR to multiple devices, creating an information ecosystem."
- "create transdisciplinary teams and pool expertise from clinical epidemiology (evidence synthesis), implementation science, and systems engineering to develop scholarly guidelines with practice strategies."
Peter J. Pronovost, MD, PhD.."Enhancing Physicians’ Use of Clinical Guidelines." JAMA. Published online December 05, 2013. doi:10.1001/jama.2013.281334
So what is a well-intentioned, conscientious practitioner to do when the history and physical examination(s), referrals and clinical data are inconclusive?
One solution or tool is non-prescriptive guidelines in the form of a systematic review, wherein "researchers gather and re-read the many clinical trials published on a given topic. For some subjects, such as the use of antibiotics for routine ear infections, the completed studies can number in the hundreds, even thousands. Each article is evaluated for methodological rigor, risk of bias and other important variables. Those that prove worthy are fed into a fresh re-analysis that provides a bigger statistical punch and a more durable conclusion."
Many governmental resources, specialty societies and academicians perform systematic reviews, but the gold standard in the field is, clearly, the Cochrane Collaboration."
“Cochrane divides human disease among 53 independent ‘review groups’ of volunteer experts who oversee each analysis. They turn out more than 400 systematic reviews annually. In recent years, the reviewers have provided definitive guidance for adult influenza vaccination (fairly useful), exercise to treat depression (no clear evidence but suggestive), and when to cut the umbilical cord postpartum (wait awhile). They also examine less critical but still important topics such as whether an electric toothbrush is superior to manual brushing (it is) or if flossing prevents cavities (who knows?).”
The Collaboration regularly finds itself defending its findings (or the lack, thereof).
For example, consider what it said about Oseltamivir (Tamiflu), a drug that had been considered to be an ‘essential medicine’ by the World Health Organization—well it actually offers “little benefit to normal adults with influenza….the drug decreases symptoms by less than a day and had no impact on survival or complications.”
- "Evidence based medicine: what it is and what it isn't" BMJ. Jan. 13, 1996;312:71-72
- Feinstein AR, Horwitz RI. "Problems in the 'evidence' of Evidence based medicine." Am J Med. 1997 Dec; 103(6):529-35. [Department of Medicine, Yale U. School of Medicine, New Haven, CT 06510].
- Comment in: Am J Med. 1998 Oct;105(4):361-2.