Friday, September 28, 2007

Clinical Guidelines and Evidence-Based Medicine

Several medical bloggers have been writing about clinical practice guidelines in the context of evidence-based medicine recently.

First, a refresher - clinical guidelines are intended to inform clinical decision-making. They are generally developed after a review of the medical evidence by experts in a particular field or an organization, and sometimes include expert opinion. They do not create or present new evidence, but generally summarize the quantity and quality of existing evidence, and add a bit of expert opinion on what the recommended course of treatment might be based on those findings. A lengthy definition of evidence-based medicine can be reviewed online, but it essentially boils down to using the triad of best evidence, clinical expertise, and patient preference to guide medical care.

Respectful Insolence points out that problems arise when a guideline attempts to apply findings from a very specific patient population to a more broad one, or vice versa. DB's Medical Rants has a series of three posts on the topic, including discussion of how a patient with multiple diagnoses makes correct interpretation and application of a guideline on one specific diagnosis more difficult. Similarly, Notes from Dr RW reminds us of the PICO system of EBM, and how guidelines may not adequately represent the "P" part - the patient/population. Dr RW notes that simply following guidelines is *not* true evidence-based medicine.

All of these bloggers make an important point - guidelines alone do not evidence-based medicine make, because they may not take into account the patient's preferences, may not represent all or the newest of the evidence, and may not be appropriate to the specific patient situation. Guidelines may serve as a good knowledge-building starting point on a topic, but following them exactly with various patients misses the three-fold nature of evidence-based medicine - patient, provider, and proof.

For more on EBM, check out these resources:
-Introduction to Evidence-Based Medicine, from the Duke University Medical Center Library
-Evidence based medicine: what it is and what it isn't, editorial in BMJ
-Evidence-based medicine: a commentary on common criticisms, commentary in CMAJ

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