gms | German Medical Science

Since the 1970's, key trends in medicine can be summarised as a call for patient centred care, evidence based clinical practice, quality improvement and a systems approach to patient safety. Recently, the role of patients has been emphasised. There is increasing interest in their voice, their involvement in decisions, coupled with a recognition that preferences, especially the informed preferences of patients, are going to be a vital part of future practice.

In parallel with these trends, the 1970's also saw the publication of data on the extent of medical practice variation, and the impact of supply-induced demand on the increasing cost of healthcare. There is also widespread concern about over-diagnosis, over-treatment and the promotion of expensive interventions, where benefits are often marginal and at the expense of a person’s quality of life.

Where does the skill of synthesizing scientific evidence lie in this emerging discourse of modern medicine? The potential to spend increasing amounts on healthcare is in contest with two other perspectives, namely the overall cost to society and the role of the informed individual in determining how decisions are made. Should clinical practice guidelines recommend only treatments supported by evidence of cost-effective outcomes? Or should guidelines be modified to present the comparative effectiveness of treatment options in ways that help patients work out what matters most to them?

If guidelines supported the comparison of treatment options, including the option of conservative management (observation rather than intervention), who then is the target user if not the patient? If patient preferences are to be considered, it is essential that such preferences be well-informed and individuals supported to become actively involved in decisions. Is it not time therefore to abandon the production of practice guidelines for clinicians to, instead, create decision support tools for patients?