If evidence-based guidelines make variations in practice explicit and unacceptable, then surely this is a good thing. Standards for conducting reviews, and even for the development and presentation of guidelines, also seem a good idea. Crack the implementation nut and we achieve better quality care.
Why then do I feel uneasy with this enthusiasm? I find myself arguing not against 'cookbook medicine' but about the ingredients. Two important ones seem to be missing: how to manage uncertainty and how to provide good psychosocial care.
What should be done when there is little or no evidence for an intervention, and how best to inform, support and care for patients in such uncertainty? These are some of the most difficult tasks in medicine and I feel that the current emphasis on evidence-based guidelines may ignore them.
The first problem I see is with the level of evidence mantra. A top-notch guideline needs a lot of high quality evidence. This means that many researchers must have tackled an area and, because this costs money, guidelines tend to cover high profile diseases where there is evidence for physical interventions, usually a drug.
For less glamorous, less common or less treatable conditions there may be no easy answer. It is certainly tricky to write an evidence-based guideline with little evidence, but little evidence does not remove the real situation to be managed. It might be countered that good reviews will identify areas of uncertainty for future research. But put together the time for review, for future research, further review and guideline production and we can put off the problem for years.
The second problem with the level of evidence hierarchy is the knee-jerk reaction to non-RCT evidence. Technical treatments lend themselves more easily to RCTs than psycho-social aspects of support and care. However, where there is no treatment or relatively ineffective treatment, the quality of the human care offered becomes, in effect, the treatment.
Numerous observational studies show that patients and their relatives need coherent information, and to feel that care is well coordinated and sensitive to their needs. Studies also suggest that these aspects are often lacking a point made independently by Patricia Dawson in last month's issue (May 1999).
But because the hierarchy sees such evidence as less robust, instead of acting on this we plan RCTs of specialist nurse support and repeat them in different difficult situations.
Then follows the debate about whether satisfaction with care is a sufficiently strong outcome. I expect some bright spark will soon suggest an RCT of being nice. After all, has the effectiveness of being nice to patients ever been proven?
Perhaps we could turn things around. Where there is enough evidence for a topnotch guideline we need to change practice quickly. Where there is little or no evidence we need guidance. Some organisations now involve patients in developing guidelines and here, ironically, consensus- based approaches and observational evidence are more useful. But to me medicine still seems happier debating technical aspects of treatment.
Certainly patients and relatives expect good technical care, but their accounts suggest variation in the management of uncertainty and difficult situations, and it is these human aspects of care they remember and complain about. So how about a review of the way that medical teams manage uncertainty and difficult situations? How long before we recognise that the current evidence-based approach is not the only way forward?