Comprises 14 contributions exploring how the implementation of outcomes data and practice guidelines is prone to stalling due to resistance to the data by its physician-users. Chapter topics include an historical perspective on the origins and significance of clinical practice guidelines, technology assessment, clinical judgment versus outcomes research, communication and physician accountability, and a case study of practice guidelines regarding otitis media with effusion. Annotation c. by Book News, Inc., Portland, Or.
Evidence-based medical practice has become something of a Holy Grail, particularly in the academic setting. Residents and medical students seem to form a chorus of white-coated crusaders with their refrain, "Show us the evidence." They are among the growing number of physicians who are convinced that objective, accurate assessment of outcomes data is possible and that it will enable them to provide better care to their patients.
In choosing the title Getting Doctors to Listen: Ethics and Outcomes Data in Context, editor Philip Boyle implies that many physicians are not as interested in an evidence-based approach as are current trainees. These physicians remain reluctant to attend to recommendations and guidelines formulated by expert panels. One expects from the title of the book that it will be an analysis of the way that the values and attitudes of doctors influence their use of evidence-based guidelines. Indeed, the first part of the book provides a description of the Hastings Center study of physicians' moral resistance to outcomes data and practice guidelines. It also includes essays that provide an interesting historical context for outcomes research itself and for the professional dilemmas it can create.
The chief strength of the book lies in part 2, which provides a series of focused and insightful critiques of the process by which practice guidelines, such as the American College of Physicians Guideline for Counseling Postmenopausal Women about Preventive Hormone Therapy and, from the Agency for Health Care Policy and Research, the Otitis Media with Effusion Guideline, were developed. Reading these essays, one comes to understand that the most important problems with such guidelines may in fact lie with the evidence itself and with the process by which guidelines are developed. The reader begins to question the process by which the "significant" questions and relevant end points are identified, the criteria with which "expert" panelists are selected, the ability of these panelists to analyze and evaluate outcomes data, and most fundamentally, whether the data themselves are adequate.
After examining the way in which four different sets of guidelines were formulated, Ross expresses concern that most of them lack the authority of evidence as well as the authority of true expertise. Culpepper and Sisk provide several excellent suggestions for improving the process of analyzing evidence and establishing guidelines, but conclude by noting that "a major contribution of the guideline development process is the systematic identification of gaps in existing knowledge." Essays by Bell and by Kelley and Koenig do an excellent job of describing how the social context of technology assessment and of medicine itself is critical not only to the questions asked but also to the data acquired and the conclusions drawn. By the end of part 2, the reader has begun to suspect that medicine, given the continual evolution of technology and the very personal context in which medical care is accepted by patients and practiced by their physicians, may not be amenable to the sort of accurate and objective assessment prescribed by the scientific method.
The third and final set of essays addresses the ethical considerations arising from the promotion of an evidence-based approach. With the exception of the contribution by Veatch, this part of the book focuses more on how the ethical foundations of the patient-provider relationship challenge the incorporation of evidence-based guidelines into practice than on the ethical challenges raised by the imperfect process of outcomes research and the development of guidelines. Having read this far, most readers will be much more concerned about the latter issue. Indeed, the primary value of the book lies in the cautionary tale it provides to the outcomes-research enthusiast.
As a high-school student, I was required to read the book How to Lie with Statistics, by Darrell Huff. I am sure that my teachers hoped to instill in me a healthy skepticism when it came to graphs and media polls. Getting Doctors to Listen is likely to instill a similarly healthy skepticism in its readers. Doctors need to do more than listen: they must also decide whether the message deserves to be heard.
Reviewed by Elena Gates, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
