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Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines
BACKGROUND: Evidence‐based medicine is the application of research findings to inform individual clinical decisions. There is a tension—both philosophical and practical—between the average result from a population study and the circumstances and needs of an individual patient. This personal account...
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
John Wiley and Sons Inc.
2018
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Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175189/ https://www.ncbi.nlm.nih.gov/pubmed/29656532 http://dx.doi.org/10.1111/jep.12925 |
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author | Greenhalgh, Trisha |
author_facet | Greenhalgh, Trisha |
author_sort | Greenhalgh, Trisha |
collection | PubMed |
description | BACKGROUND: Evidence‐based medicine is the application of research findings to inform individual clinical decisions. There is a tension—both philosophical and practical—between the average result from a population study and the circumstances and needs of an individual patient. This personal account of “evidence‐based” trauma care illustrates and explores this tension. THE CASE: The author, a keen athlete, describes her experience of a high‐impact cycle accident that led to limb fractures (which were diagnosed and treated according to evidence‐based guidelines) and also an occult injury to the cervical spine (which was not diagnosed at the time). Some evidence‐based guidelines are reviewed and applied to the case. The clinical record described the cycle accident as a “fall.” Initial assessment directed the clinicians' gaze to the obvious injuries, whose treatment was straightforward. On admission, the patient (aged 55 years at the time) was offered “falls prevention” via a guideline‐based checklist. Several months later, neurological sequelae indicated possible damage to the cervical spine. But the NICE Guideline recommending cervical spine imaging in cases of high‐impact trauma had not been considered—perhaps because the clinical narrative had been prematurely assigned to the script of “older person with fall.” Furthermore, the author, who was (appropriately) treated with neurosurgery, was surprised at the response of clinical colleagues, based on application of an irrelevant section of a guideline, that her cervical discectomy was “nonevidence based.” Nonsteroidal anti‐inflammatory drugs for postoperative pain were indicated in this patient even though they were not recommended for the average patient. CONCLUSION: As Sir John Grimley Evans' warned, we should avoid using evidence‐based guidelines in the manner of the fabled drunkard who searched under the lamp post for his key because that was where the light was, even though he knew he had lost his key somewhere else. |
format | Online Article Text |
id | pubmed-6175189 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2018 |
publisher | John Wiley and Sons Inc. |
record_format | MEDLINE/PubMed |
spelling | pubmed-61751892018-10-15 Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines Greenhalgh, Trisha J Eval Clin Pract Special issue: 2018 Philosophy Thematic Issue BACKGROUND: Evidence‐based medicine is the application of research findings to inform individual clinical decisions. There is a tension—both philosophical and practical—between the average result from a population study and the circumstances and needs of an individual patient. This personal account of “evidence‐based” trauma care illustrates and explores this tension. THE CASE: The author, a keen athlete, describes her experience of a high‐impact cycle accident that led to limb fractures (which were diagnosed and treated according to evidence‐based guidelines) and also an occult injury to the cervical spine (which was not diagnosed at the time). Some evidence‐based guidelines are reviewed and applied to the case. The clinical record described the cycle accident as a “fall.” Initial assessment directed the clinicians' gaze to the obvious injuries, whose treatment was straightforward. On admission, the patient (aged 55 years at the time) was offered “falls prevention” via a guideline‐based checklist. Several months later, neurological sequelae indicated possible damage to the cervical spine. But the NICE Guideline recommending cervical spine imaging in cases of high‐impact trauma had not been considered—perhaps because the clinical narrative had been prematurely assigned to the script of “older person with fall.” Furthermore, the author, who was (appropriately) treated with neurosurgery, was surprised at the response of clinical colleagues, based on application of an irrelevant section of a guideline, that her cervical discectomy was “nonevidence based.” Nonsteroidal anti‐inflammatory drugs for postoperative pain were indicated in this patient even though they were not recommended for the average patient. CONCLUSION: As Sir John Grimley Evans' warned, we should avoid using evidence‐based guidelines in the manner of the fabled drunkard who searched under the lamp post for his key because that was where the light was, even though he knew he had lost his key somewhere else. John Wiley and Sons Inc. 2018-04-15 2018-10 /pmc/articles/PMC6175189/ /pubmed/29656532 http://dx.doi.org/10.1111/jep.12925 Text en © 2018 The Authors Journal of Evaluation in Clinical Practice Published by John Wiley & Sons Ltd This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. |
spellingShingle | Special issue: 2018 Philosophy Thematic Issue Greenhalgh, Trisha Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines |
title | Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines |
title_full | Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines |
title_fullStr | Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines |
title_full_unstemmed | Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines |
title_short | Of lamp posts, keys, and fabled drunkards: A perspectival tale of 4 guidelines |
title_sort | of lamp posts, keys, and fabled drunkards: a perspectival tale of 4 guidelines |
topic | Special issue: 2018 Philosophy Thematic Issue |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175189/ https://www.ncbi.nlm.nih.gov/pubmed/29656532 http://dx.doi.org/10.1111/jep.12925 |
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