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European Heart Journal Advance Access originally published online on October 5, 2005
European Heart Journal 2005 26(22):2474; doi:10.1093/eurheartj/ehi560
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© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Evidence-based vs. ‘impressionist’ medicine: how best to implement guidelines

William H. Fennell

Department of Cardiology
Cork University Hospital
Cork, Ireland
E-mail address: whfennell{at}eircom.net

John Worrall

Department of Philosophy, Logic and
Scientific Method
London School of Economics
London, UK

Bassand et al.1 make a good case for increased use of guidelines. However, they underestimate the role for clinical judgement, patient choice, and physician concerns about cost effectiveness and polypharmacy. Randomized clinical trials and meta- analyses have enormously improved the data base to allow guidelines to be formulated and improve knowledge in pathophysiology and therapeutics in so many countless areas. For this, all clinicians are grateful. However, on a daily basis, the clinician has to make decisions for the individual patient and does not always have the same confidence as the guideline makers that the patient fits the criteria for a specific pathway. Even more importantly, because the morbidity/mortality benefit is likely to be so small, the odds are very strong and the individual patient is most unlikely to benefit. When one presents the numbers needed to treat (NNT) for a benefit to the patient, they are frequently unimpressed and opt not to proceed. Clinicians will regularly opt to compromise, sensibly in our view, with the patient and choose a more user friendly regime to facilitate compliance.

All will agree that the health authorities and the professionals should collaborate to facilitate guideline development and rationalization to guard against guideline overload. We have reservations about industry being involved in guideline development and promotion, as historically their promotions have emphasized relative risk reduction with little reference to absolute reduction and NNT. We would suggest that information on numbers treated effectively and ineffectively should also stand side by side. For a counter opinion, we would recommend the work of James Penston.2

References

  1. Bassand JP, Priori S, Tendera M. Evidence-based vs. ‘impressionist’ medicine: how best to implement guidelines. Eur Heart J 2005;26:1155–1158. Published online ahead of print May 3, 2005.[Abstract/Free Full Text]
  2. Penston J. Fact and Fantasy in Medical Research: The Large-Scale Randomised Trial. London Press, 2003.

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This Article
Right arrow FREE Full Text (PDF) Freely available
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26/22/2474    most recent
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