• Open Access

Evidence-Based Healthcare in Context: Critical Social Science Perspectives

Edited by Alex Broom and Jon Adams , Published by Ashgate , Surrey UK , Paperback , 195 pages , ISBN-978-0-7546-7981-3 , RRP $99.95

Reviewed by Dr Virginia Dickson-Swift, La Trobe Rural Health School, La Trobe University, Victoria

In the ever-changing world of western health care, this book provides an excellent examination of the debates surrounding evidence-based medicine (EBM), evidence-based practice (EBP) and evidence-based health care (EBHC). Using a sociological lens, Broom and Adams have drawn together an excellent edition that explores the rise of evidence-based health care in contemporary western medicine. The chapters within the book focus on a range of criticisms, including the complex nature of clinical decision-making and the absence of patient preferences for treatment from the contemporary debates. Drawing on examples from both the clinical and patient perspective, including medical oncology, neuro-rehabilitation, complementary and alternative medicine and midwifery practice, the book provides concrete examples of the issues that are faced by patients and clinicians alike with regard to health care decision-making.

The book is divided into three main sections that focus on the theoretical and practical applications of EBM within health care settings. The early chapters provide an excellent overview of the historical developments with regard to the rise of evidence-based medicine and evidence-based practice and locate those movements within the broader movement of evidence-based health care. The limitations of EBM are discussed within a clinical setting and the difficulties associated with clinical decision making are outlined. This section considers the fact that most practitioners have a good understanding of the role and value of EBM in their daily practice, but the ability to utilise it is not often considered. The political nature of EBM is also raised as is the issue of the production of knowledge within the broader health sciences. One of the most important points raised in the first section is that despite the fact that the value of EBM is well understood, its use within clinical decision-making is sometimes of limited value due to the absence of the patient experience within the debates.

The second section of the book addresses this issue by providing practical examples of the use of Evidence in the Clinic. Chapter 4 draws on interview data with surgeons and radiologists and provides practical examples of the tensions with regard to the use of evidence in clinical settings. It highlights how organisational structures create large variations in the impact of evidence in clinical practice and provides an understanding how contextual factors such as different patient characteristics, technology available and decision-making processes all affect the ability of clinicians to work in an EBM framework.

Chapters 5 and 6 provide further examples of the failure of EBM to sufficiently acknowledge the complexity and multidimensional nature of clinical decision-making. Drawing on examples from neuro-rehabilitation and interviews with oncology nurses and consultants, these chapters raise the question of what constitutes evidence. The examples provided highlight the complexities of clinical decision-making within the clinic by outlining the range of interactions that constitute knowledge production which often include social processes. The over-reliance on narrowly defined quantitative evidence from clinical trials is questioned, and the value of using intuitive subjective qualitative methods to inform clinical judgements is considered. The importance of a holistic approach to patient care that takes into account cultural, spiritual, psychological and emotional aspects is outlined.

The third section of the book focuses on Evidence on the Margins and provides some excellent discussion of the limits of biomedicine and the role of the randomised controlled trial as a measure of evidence. Drawing on the narratives of a range of patients and practitioners, the authors call for practitioners to extend their practice beyond what is taught in traditional health and medical courses. The chapter focusing on complementary and alternative medicine (CAM) highlights the tensions and dissatisfaction with biomedical science and outlines how the statistics on cure rates often lead terminally ill patients to try new things. This final section outlines the limitations of the reductionist model of health and illness, and shows how many patients view evidence and scientific knowledge with trepidation. The subjective nature of health and disease is raised once again, and the importance of considering other aspects of a person's life including emotion and spirituality on disease progression are largely ignored by biomedical models constrained by strict EBM criteria.

In the final chapter, the authors provide students with some understanding of the political processes that determine much of what is defined as EBM. Using examples of breast and prostate cancer, this chapter highlights how the political processes can cloud or inform EBM. The ability to reflect on both the political and social process that shape EBP is important for all students in health and social sciences. Sadly, many students of the pure health disciplines do not have the background required to consider these significant debates. It is important that students of health and social sciences are encouraged to be critical about the subjective aspects of knowledge production in health care.

This book is a useful addition to a recommended reading list for students studying in the health sciences and social sciences. It raises a numbers of debates about the role of EBM as a contemporary social movement shaping patient care, and what that means for the training of our students into the future. One of the highlights for me as a lecturer teaching evidence-based practice to a range of health science students, is the need to consider the range of background-knowledge required by students for understanding the complexities of EBM. The authors of this book have provided good evidence that a critical social science perspective is required, and now it is up to us to embed that understanding into our undergraduate programs that espouse the value of EBM in the wider context of EBHC.