Monday, April 23, 2012

Instinct, Reasoning, and Guidelines

An important aspect of The Gold Standard is that Timmermans and Berg attempt to explore the reasoning and psychological factors of the individuals when attempting to understand why standardization in the medical field is met with either acceptance or resistance.  I believe that this is important because it is different that simply analyzing group dynamics within the profession.  My interpretation of why compliance with clinical practice guidelines is relatively low is that on the individual level, physicians are instinctively not receptive to these guidelines.  As illustrated in this work, evidence based medicine is based on probability and statistical constructs.  As a result, such guidelines function to treat the “average patient,” a constructed through such statistical analysis.  Physicians, however, live in a different reality than the construct of the average patient, one where probability cannot always be trusted.  While physicians may accept the principle of the idea of evidence based medicine and guidelines, their instinct may overtake their reasoning in actual practice.  On the individual level, physicians may agree that the evidence based guidelines are generally valid, but decline to follow such guidelines after analyzing specific cases and determining that they are not appropriate for the situation.  As a result, a dichotomy is created between what physicians say they believe and what they do in while practicing. 

I believe that the problem with standardization is the threat it poses to professional autonomy.  The professionalization of the medical field was based upon the concept of autonomy as it allows patients to put more trust in their doctors and ultimately gives doctors moral and scientific authority.  If we allow standards to intervene in medical decision making, physicians will no longer be able to exercise their own professional discretion, harming the credibility of the entire field.  This is why, I believe, that while evidence based medicine is an important part of clinical medicine, analyzing patients and treatments on a case by case basis should not be completely overshadowed by standardization.


  1. I agree with Chelsye on the point of standardization being harmful to the profession. During the discussion of whether medicine is an art or science, I believe we came to the conclusion that it is both - a science backed up by the creativity and decision-making of physicians. Standardization would try to eliminate the inherent variability between caregivers, thus taking the art and enforcing a pattern on it. While again I agree that evidence-based medicine is important from a scientific and logical point of view, I do not believe that it should completely dominate the decision-making process. The mastery and intuition of doctors gained through experience are the only things setting them apart from a chimp with a checklist (aka someone with a bachelor's degree). If doctor's always have to second guess themselves because something deviates from a mapped diagnosis, I feel it could also take away from their learning experience, because they could be attracted to the standardized care - it might take off some intellectual load off during bedside examinations, but at what cost?

  2. Is standardization via evidence-based medicine harmful to the patient though? I don't think it is.

    I understand how many people believe standardization harms the medical profession, stifles doctors' creativity, mastery, intuition, and ideology and is not conducive to treating patients on a case by case basis. However, standardization via evidence-based medicine is extremely helpful to the patient in terms of the overall improvement of the quality and safety of the treatments that doctors utilize based on proven effectiveness rather than their sole ideology that they are effective. Several examples of common medical practices based on ideology rather than evidence include antibiotics being used to treat ear infections, the use of cough syrup by children, and surgery to relieve back pain. None of these treatments are proven to be effective. Some are actually more harmful than helpful to the patient.

    I believe standardization via evidence-based medicine provides a minimum standard of expected care and as a result results in the improvement of medical quality and safety. I also believe evidence-based medicine has its benefits in terms of aiding the treatment of groups of individuals and thus can be applied to patients on a case by case basis. This is because evidence-based medicine studies show that treatment A is particularly effective for treating group B for condition C, whereas treatment D is effective for treating group E for illness F. Finally, evidence-based medicine is a huge component of comparative effectiveness research in national health reform. If doctors used a treatment that is proven to be consistently effective in treating a particular condition based on this research, we will be narrowing the range of uncertainty in medical practice, improving the chances of reducing illness and death, and save money on treatment and care that is not as effective, not effective at all, or actually complication causing (and then save money on the treatment of those complications too).

    While I believe evidence-based medicine should be utilized more consistently by physicians, this does not mean that doctors should not use their own judgement in choosing the specific treatment that will be the MOST EFFECTIVE for a particular patient. Patients should also be make aware of all of the treatment options as well as their effectiveness and be allowed to have a say in what treatment they receive based on this information.