Family Practice Vol. 16, No. 5, 543
© Oxford University Press 1999
Book Reviews |
Getting research findings into practice.
Professor of General Practice at the University of Edinburgh
A Haines, A Donald (eds). (170 pages, £19.95.) BMJ Publishing Group, 1998. ISBN 0-7279-1257-7.
This monograph is an anthology of essays on one of the hot topics of the day—the gap between evidence of best practice (whether this means effectiveness or efficiency or both) and its application to day-to-day practice. The text includes 15 chapters co-authored by 38 contributors, some of which had previously been serialized in the BMJ during 1998.
In the past I have acted as a devil's advocate against the swamping of general practice with inappropriate guidelines and have been concerned about the centralizing implications of the National Institute of Clinical Excellence (NICE) and the Commission for Health Improvement (CHIMP). So I assume I was invited to review this latest contribution to the ‘evidence-based medicine' movement as a potential critic. As I picked my way through the early chapters, my fears were confirmed and my notes became more negative. Could it be that the past use of clinical experience was as bad as all that? Were textbooks and clinical teaching really conspiracies against truth? Was all research other than the Random Controlled Trial to be discarded? Was it true that only 7 of 793 published trials in one sphere of activity (computerized decision support) were completely acceptable to the meta-analyst?
However, the book contains many notably interesting chapters on how evidence has either changed or has not changed practice or could change practice, which escape from the straightjacket of Cochrane-type political correctness. When I re-read some of the chapters I had at first wanted to criticize, I recognized I was becoming a prisoner of the prejudices against progress I have spent a professional lifetime trying to break down.
All the contributions contain ideas and observations of interest and merit. The chapters I found most interesting were the two on decision support—surely destined to become of great use in the future, as long as doctor– computer relationships don't take over from doctor– patient relationships. In complex clinical problems (albeit often hospital-based) where the advantages and disadvantages of different policies have high tariffs in terms of life and death or of cost, we cannot afford to under-use the capacity of IT to recall or interpret what the human mind cannot cope with. Similarly, in general practice the inclusion of information about patients' attitudes to risk-taking will help take the impersonality out of many current guideline recommendations.
Other interesting chapters included one contribution to evidence-based practice from the field of health economics and a final chapter contrasting the different uptake of two innovations in perinatal care between obstetricians and neonatologists. This probably summed up most sympathetically why, despite the good will of everyone, there will be unevenness in implementation of change for some time to come.
It is a pity that multi-author books always look like multi-editor books. The well-written introduction by the authors could as easily have been the last chapter as the first. Perhaps it should have appeared twice!
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