Paradigms found
CMAJ 1997;157:642
The comments by Dr. Graham Worrall and associates ("The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review," CMAJ 1997;156:1705-12) and Dr. Robert S.A. Hayward ("Clinical practice guidelines on trial," CMAJ 1997;156:1725-7 [full text / résumé]) about clinical practice guidelines (CPGs) are excellent and timely.
We agree with Hayward that CPG initiatives should continue, with a focus on validating methods and assessing effectiveness, as suggested by the data in Hayward and associates' article "Canadian physicians' attitudes about and preferences regarding clinical practice guidelines" (CMAJ 1997;156:1715-23 [full text / résumé]). These authors document that physicians may not use CPGs to any great degree in practice decisions and that they make decisions largely on other grounds. Have physicians appropriately valued existing CPGs, or have they undervalued them? Will more and better CPGs change that valuation?
Worrall and associates state that evidence-based CPGs "are the main tool for introducing evidence-based medical care." In contrast, many believe that clinical epidemiology is one of several core basic sciences that every physician must now have.1 A health care professional educated in this area is best able to accommodate evidence and CPGs, when possible, while acknowledging their real limitations. Educating physicians about the principles of epidemiology and developing a professional culture of open discussion about our values and how we make decisions may be a better way to ensure that evidence-based medical care is introduced successfully, yet without uncritical acceptance.
We believe that making even better decisions requires a more complete theory of medical choice. Traditional medicine, as one such theory, does not accommodate advances in measurement, statistics and clinical epidemiology. Evidence-based medicine, as another, captures these. Our profession urgently needs a debate over the relative importance or value of causal and prognostic evidence (clinical epidemiology) in making medical decisions. Evidence-based medicine is now nearing dominance within research, journals, academic practice and political discussions about Canadian medicare (e.g., the National Forum on Health). However, medical decisions take into account many factors apart from epidemiologic evidence, including preferences, ethics and patterns of resource allocation. A new theory should try to incorporate the best parts of traditional medicine, evidence-based medicine and some of these other considerations. From such a perspective, the efforts and debates concerning CPGs will seem but one small step toward far wiser decisions.2
Glenn W. Jones, MSc, MD
Jim Wright, BSc, MD
Hamilton, Ont.
References
- Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. 2nd ed. Toronto: Little, Brown & Co; 1991:xiv.
- Jones GW, Sagar S. Rationing health care. World & I 1996;11:18-9.
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