Guidelines and Mindlines.

Modern medicine is dominated by guidelines. For most doctors, hardly a day goes by without consulting a document with the latest guidance on managing one medical condition or another. At the same time, guidelines and their place in medicine are being called into question as never before. In the most downloaded article in the BMJ this year, for example, Trisha Greenhalgh and her colleagues offered a catalogue of the limitations of guidelines. These include the influence of vested interests like pharmaceutical companies that hijack the evidence ‘brand’ for commercial purposes, sometimes selecting or distorting research to do so. Then there is the sheer number of clinical guidelines, now so huge that a doctor who pursued all of them would have to give most patients a bucketful of medication every month, much of it in the name of preventive medicine – even though the statistically significant benefits may be marginal. Guidelines for single conditions map poorly onto complex multimorbidity, so that they are least suitable for exactly the kinds of patients who consult the most. Inflexible rules and computerised prompts have encouraged a style of medical care that is driven more by managers and finance officers than the needs and wishes of patients. Guidelines have another limitation that possibly trumps all the others: by and large, doctors do not actually follow them. Twenty years of advice, exhortations and admonitions from the Evidence-Based Medicine (EBM) movement have failed to stamp out variation between individuals, regions or countries in the management of a wide range of conditions. It is, of course, possible to argue that we simply need more evidence, along with better guidelines. If we could persuade research scientists to be more rigorous, the argument goes, everything would be all right. We would then only need stronger incentives to make doctors compliant, and better health education to help patients make rational choices. In contrast to this view, an increasing number of critics are suggesting that the problem with guidelines is far more fundamental – the kind of problem that philosophers call epistemological. According to this argument, the people who inhabit EBM and generate guidelines – the researchers, policy makers, managers and doctors – are living in a kind of intellectual bubble, where they recognise only certain types of knowledge and practice as valid, and discount anything that does not fit with their world view.