The British Medical Journal (BMJ) has published a paper on 16th May, 2016, discussing the interventions required in evidence-based medicine to cater to the healthcare needs of individual patients. It is believed that evidence-based medicine has been incorporated into clinical practices for the past 20 years, effectively contributing towards healthcare advancements.
However, clinicians and patients are not fully content with the implementation of evidence-based medicine. Health guidelines have been a salient contributing factor that has directly influenced the working of evidence-based medicine in clinical settings. Although guidelines are formulated with the intention of improving the quality of healthcare available to the general population, they are said to be contributing towards making medicine bureaucratic and authoritarian. The instituted guidelines are lengthy and too technically complex to be understood by laymen, primarily being used to communicate the latest evidence about specific diseases to the clinician.
However, unlike the aforementioned claims, the guidelines have been found to have certain limitations. Primarily, they are found to be focused on a disease-oriented approach without considering other factors such as a patient’s preference to decide the course of their treatment and the options of alternation treatment. Another limitation is the guidelines’ unanimous focus on just one disease.
In practicality, multi-morbidity exists, which means individual patients do not suffer from simply one medical condition but experience multiple conditions simultaneously. The guidelines seem to have missed such considerations by solely focusing on one condition at a time.
These medical rules nullify the effects of other health conditions, negating the right of a patient to make an optimal choice which caters to all of their individual medical needs. In accordance with this, the risks of drug-drug, drug-disease interactions and inefficacious polypharmacy are neglected. The biggest flaw these guidelines hold is their inflexibility towards shared decision-making between the doctor and the patient. Guideline recommendations have clearly failed to recognize a patient’s role in the decision-making process regarding their current health, with regulations being formulated from the perspective of health professionals, who do not give due weightage to the perspective of individual patients.
Therefore, this study recommends making amendments to the guidelines so that they cater to the needs of individual values and preferences of patients instead of simply tending to the needs of the population at large.
Modifying Guidelines for Individual Patients
“Guidelines, not tramlines,” said David Haslam, Chair of the National Institute for Health and Care Excellence (NICE), at its 2015 conference. But to create an impact, both professionals and patients will have to work in harmony. The importance of guidelines, in no way can be negated; however, it is noted that “almost two thirds (62%) of research referenced in primary care guidelines is of uncertain relevance to primary care patients. Only 11% of American cardiology recommendations are based on high levels of evidence, with 48% based on the lowest level of evidence and expert opinion.”
Even in recommendations based on high levels of evidence, comorbidity and vulnerable groups are not included. For optimized healthcare recommendations, the excluded groups should be added in the discussion.
Due to the disparities involved, the following criteria should be indicated in the guidelines: quality of evidence, information about treatment effect size, probability of a treatment’s benefit, characteristics of a patient group and the uncertainties limiting result extrapolation.
While an expert writes a certain guideline, they should ensure that they are unbiased in their opinion and that they aren’t instructing directions to the clinician or a patient.
A paternalistic approach has penetrated deep into our healthcare systems which cannot be changed overnight. But, with an increase in informed public, this paternalistic approach is destined to reduce. The treatments tend to become patient-centered, where the clinician and patient are engaged in a conversation that encourages questions from the patient.
The questions that may come across in such clinical practices would include: “What are the other treatment options? What matters to you? What are your hopes for the future and priorities for your health?” Once the notion of supremacy of the doctor is challenged, a shared decision making will become a regular clinical practice.
The need of the hour is to value every individual as an entity while proposing a treatment or intervention and not treating population as sheep herds.
The study has explained this phenomenon with an apt example. It suggests that if the health of individual patients is given priority, it will inevitably aggregate to a healthier population. For instance, a folic acid supplement is prescribed to a sample population to fight off congenital defects but soon after this, a larger population starts to exhibit side effects of the treatment. Consequently, the use of folic acid supplement is stopped but it is found out that maybe one individual in the population was benefitting from the treatment and now their right to treatment is taken away just because the majority didn’t require the treatment. This should not happen with the interventions giving prior importance to every individual.
This paper also pointed out how the efforts of organizations are wasted in duplicating guidelines. Whereas if these efforts were channelized into presenting the information in a way that effectively delivers its recommendation to the laymen, the impact of these guidelines could be magnified manifold. The long process of facilitating patients with updated information, both formally and informally, should be a core priority.
In addition to this, doctors who think every case through a ‘one size fits all’ approach will have to change. Their consultation style needs to be reversed so that the patient is the focal point and all subsequent interventions and treatment decisions are made through a doctor-patient consent.
In this regard, the ‘pay for performance’ criterion also has to change, as it acts as an obstruction to adapting new styles. The conventional approach compels doctors to make their decision in compliance with the guidelines but not with the patient’s values and preferences.
Decision aids for individual patients, clearer guidelines and patient-centered consultations should be the prime areas to work on. Once these sectors are on the right track, evidence-based medicine will eventually incorporate tailor-made interventions into routine clinical practices, leading to value every patient alike.