”You're either with us or you're against us.” Dominant discourse in health care practice

Hannah Piterman

‘Evidence base medicine has become a political and ideological hot potato. The cry has gone out for clinicians to declare their allegiance, either with the ‘hard science’ of clinical epidemiology, or with the traditional values of personal compassion and patient centred medicine

(Smith and Taylor, 1996, p 105 in Greenhalgh and Worrall’ 1997)

Abstract

Evidence–based approaches to health care decision making, originating in clinical medicine, and clinical epidemiology are assuming increasing significance as the concept disseminates through the broader health–care field (Upshur, 2001). The substantive basis of evidence based practice (EBP) lies in epidemiology as a set of statistical methods and investigational techniques for summarizing and analysing health states in populations (Charlton 1996a in Charlton, 1997, p 87). Those opposed to the wholesale reliance on evidence-based practice to define health care knowledge and determine practice argue that health care is complex and heterogeneous and does not fit into a model in which clinical encounters are reduced to unidimensional problems and neatly solved by recourse to research trials (Greenhalgh 1996, Hope 1995b, Asch and Herrschey 1995 in Greenhalgh & Worrall, 1997; Lanier, 1995 in Charlton, 1997).

This paper emanates from research I undertook to evaluate a Monash University project that featured strategies to address the discord between evidence-based medicine and current practice in four hospital based stroke units around the State of Victoria (Australia). My findings concur with the literature indicating that significant barriers to the uptake of evidence exist at an individual, systemic and organisational level (Gray, 1996; Crabtrree & Miller, 1998;Donald, 1998; Thorsen & Mäkelä, 1999; Grol & Grimshaw, 1999; Solberg, Brekke, Fazio et al., 2000). My findings further point to confusion surrounding the role, meaning and application of evidence in the ‘real world’; and a marginalisation of those forms of knowledge that do not fit into the language of randomised control trials. Issues regarding one’s identity as a health care professional in the face of evidence emerged as health care professionals propagating forms of knowledge that did not concur with the dominant paradigm expressed feelings of alienation (Piterman & Anderson, 2002).

The paper argues that the elevation of evidence from ‘tool kit’ to ‘quasi-religion’ is stymieing debate, creating circumstances in which to contest the dominant paradigm can lead to retribution and scapegoating, both real and imagined (Schwartz, 1990; Krantz, 1995 in Kram & McCollom, 1998). While evidence-based-practice has its place, when it becomes idealised, politicisation and consequent bifurcation result, usurping the potential benefits that are associated with a ‘contained’ concept of evidence-based-practice. Its idealisation constitutes a fantasy world framed in the language of rationality, practicality, and technology. In a rationalist paradigm emotions are consistently devalued and marginalised, while rationality is privileged as an ideal for effective organisational life (Putnam & Mumby, 1993; Shrivastava & Schneider, 1984 in Ashworth & Humphrey, 1995, Rees, 1995). This constitutes a psychic defence against emotion, which threatens the core essence of health care, what Hutton (1997) refers to as its ‘core technology’. Healthcare is a highly complex enterprise (Plsek & Greenhalgh, 2001; Plsek & Wilson, 2001) and requires the capacity to transcend rationality and embrace the road to understanding through the experience of emotion.

While increased efforts have been made to understand the barriers to the uptake of evidence, and significant progress has been made in appreciating the complexity of the health care system, a common-sense understanding of evidence-based practice as a tool rather than a solution is regrettably uncommon. In this paper I seek to progress the understanding of the resistance to EBP by exploring conscious and unconscious dynamics associated with its ‘authority’ status as a tool of policy and politics, and to throw light on the impact of dominant paradigms, as social defences (Jaques, 1955; Menzies, 1970) against thinking, creativity and best practice.

Introduction

The last decade has seen a massive drive towards health care reform. The agenda has involved a number of initiatives including managed care, co-ordinated care, purchaser provider models, quality improvement initiatives and cost rationalization models. This paper explores the dynamics around a significant initiative in health care reform – evidence-based practice. One cannot work in health care without in some way interacting with the notion of evidence-based practice. In this paper I argue that events in the broader domain have shaped the direction of the health reform agenda distorting its focus, balance and priorities and creating circumstances in which dominant paradigms act as social defences (Jaques, 1955; Menzies, 1970) against thinking, creativity and best practice. Evidence-based practice has become a phenomenon in health care, transcending its definition. This impacts on the way it has been defined and operationalised to inform decision-making in health care. Indeed, evidence-based practice has become politicised and idealised rendering it a tool of politics and diminishing its effectiveness as a servant of medicine.

What is evidence-based practice?

Evidence-based approaches to health care decision-making are underpinned by tools developed through epidemiology – in particular the reliance on randomised control trials and systematic reviews, and other related disciplines including biostatistics, clinical economics, and medical informatics to inform clinical decision making. The outcome is a set of statistical methods and investigation techniques for summarising and analysing health states in populations. Governments are encouraging its implementation as the gold standard, defining best practice in health care. Indeed, any initiative seeking government support requires the stamp evidence-based practice to give it the necessary imprimatur for receipt of funding. Centres of evidence- based medicine are being set up in medical faculties and government departments that propose an approach to evidence that ‘de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision-making, and stresses the examination of evidence from clinical research. Evidence-based medicine requires new skills of the physician, including efficient literature searching, and the application of formal rules of evidence in evaluating the clinical literature’ (Centre for Health Evidence, 2003, p 1).

To appreciate the full significance of what has been heralded as a new paradigm shift and a new philosophy of medical practice and teaching, one needs to understand the broader health care context and the socio-political milieu in which it sits.

The broader political context

Of significance to the changing health care climate is the importation of a managerial reform agenda to frame and guide the funding and delivery of health care. Managerialism is part of a trend in the western world, where rationalism is all pervasive and the business market metaphor becomes the dominant metaphor as far as social policy is concerned (Long, 1999; Soros, 1997, 2003). In a culture of rationalism, measurement is reified to the extent that accountability through process is relinquished for accountability through quantifiable results (Boston et. al. 1996 in Hancock, 1999). The market is blind to equity, need and compassion, and emotion is eschewed (Considine, 1987; Komesaroff, 1999; Halasz, 1999). Objectivity and neutrality become idealised states beyond scrutiny or question, a reflection of the elevation of the status of rationality as an end in itself (Rees, 1995).

The re-emergence of rationality as a defining paradigm has occurred in the context of the confusion and uncertainty of our postmodern era. Postmodernism has no underpinning morality. It is devoid of emotion, aesthetics and ethics (Dacher, 1996). Unbridled, uncontained and unconstrained, it can lead to dangerous and destructive ideologies, leaving us at the mercy of the presuppositions of the latest insidious revisionist agendas. On the surface a rationalist agenda, in seeking order, may be viewed as a defence against the chaos of a postmodern world in which truth and reality are but constructs. However, in its attempts to create order it engages in the very spin against which it is defending itself. It thrives on what Rabbi Jonathan Sacks refers to in ‘The Dignity of Difference’, as the notion of ‘universality’, a state in which differentiation cannot be tolerated (Sacks, 2002). A non-differentiated fantasy world is imposed via fragmentation, splitting and scapegoating, ostracising those who challenge or question its tenets. In his paper, ‘The Global Society and its Enemies’ Soros contends that ‘today’s open society, finds it difficult to acquire a purpose that will command allegiance except by identifying the enemy… The real threat to open societies comes from ideologies that offer simple but false answers to difficult and often insoluble problems’. (Soros, 2003, p 5) Yet we are expected to collude with the split and suspend our rational and critical faculties in a blind and unquestioning faith of the efficacy and rightfulness of these fundamentalist ideologies (White, 1997). This is couched in, what Saul refers to as, rhetoric, propaganda and a dialectic which attempts to normalise what is untrue by constructing abstract notions that obscure real events, narrow public debate and misuse and corrupt language (Saul in Pring, 1997). Hence the title of my paper, ‘You’re either with us or against us’.

No system sits in isolation (Senge, 1990) and parallel processes operate such that the penetration of the rationalist culture into the health care domain has transformed the language and philosophy of health care. Rationalism now defines and shapes health care, its structure, systems, tools and practices in its image.

Evidence-based practice as an omnipotent state

This paper is not an attack on evidence-based practice. I do not attempt to question the efficacy of evidence-based practice. Sacket et al. define evidence-based practice as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (Sacket et al., 1996, p 71). In its right place and contained, evidence has a place as a tool and servant of medicine, in assisting doctors to make the best decisions. Review of one’s practice in the light of evidence should be an essential feature of professional practice. Do routine episiotomies constitute good practice? Is there evidence to suggest that administration of analgesics, by masking symptoms, impedes diagnosis? Is the administration of heparin likely to reduce the rate of extension and complication for strokes? Is treating children who allegedly suffer from Attention Deficit Hyperactivity Disorder (ADHD) with amphetamine-based drugs, like Ritalin, the best solution for dealing with so-called hyperactive children? These are appropriate questions, which deserve consideration.

This paper is an attack on an omnipotent notion of evidence-based practice; it is an attack on a loss of boundary associated with evidence-based practice, which has seen it catapult from ‘tool kit’ to ‘quasi religion’; it is an attack on the fantasy world of precision and rationality, in which ambiguity and uncertainty have no place; and it is an attack on an agenda that vilifies those that question its very tenets.

Evidence-based practice constitutes a new truth and authority regarding scientific practice, resulting in the undermining of other truths, in particular the array of truths that takes place in the clinical encounter. The outcome is a scenario in which the nature of the clinical relationship is usurped, and thinking, creativity, values, emotion, judgment and humanity are diminished. In its stead we have a scenario where numerical rationality is elevated so that it is synonymous with clinical truth.

Despite a call in the recent literature for greater integration between physical science and humanities (Upshur, 2002; Buetow, 2002; Halasz, 1994; Harari, 2001), and despite a literature base that is increasingly acknowledging the complexity of the clinical landscape, (for example the literature on complex adaptive systems (Plesk and Greenhalgh, 2001; Greenhalgh & Worral, 1996; Pringle et al., 2002; Plesk & Wilson, 2001)) the core belief and practice of what is being promulgated as best practice in the literature aligns quantitative methods for evidence synthesis with supremacy, such that the randomised control trial, mega trials, meta analysis and systematic reviews remain the ascendant basis for clinical decision making (Upshur, 2001).

Evidence-based practice, however, is not universally accepted. Resistance to its implementation is a source of great frustration to its proponents. Those opposed to the wholesale reliance on evidence-based practice to define health care knowledge and determine practice argue that health care is complex and heterogeneous, transcending ‘information’ and ‘evidence’. Medical practice does not fit into a model in which clinical encounters are reduced to unidimensional problems and neatly solved by recourse to research trials (Greenhalgh, 1996, Hope, 1995b, Asch & Herrschey 1995 in Greenhalgh & Worrall, 1997; Lanier 1995 in Charlton, 1997). Significant resources have been devoted to understanding the basis of such resistance and to the development of strategies to encourage the embracement of evidence-based practice (Gray, 1996; Crabtree & Mille,r 1998; Donald, 1998; Thorsen & Mäkelä, 1999; Grol & Grimshaw, 1999; Solberg et al., 2000). While this literature base incorporates systemic and organisational reasons for difficulties in implementing an evidence-based approach, it does not challenge the pre-eminence of quantitative evidence, merely offering us more creative ways of implementing what constitutes an accepted truth (Grol & Grimshaw, 1999; Solberg et al., 1997). Nevertheless it does relieve the pressure on clinicians for their failure to adhere to clinical guidelines.

In my own work I have been involved in a federal government-funded initiative in Australia referred to as the Clinical Support Systems Program^1, to explore ways of bridging gaps between evidence and clinical practice in four hospital-based stroke units around the State of Victoria. The initiative sought to develop a clinical management program to introduce best practice, through evidence. While the project was structured to encourage clinicians to pursue strategies to implement evidence, what constituted evidence was non-negotiable. The terms of reference of the project did not provide the freedom to question the nature of the evidence. Evidence was defined a priori and clinicians were required to follow the evidence guidelines. Some clinicians (mainly nurses) felt empowered by some of the evidence guidelines, as the guidelines provided an opportunity to challenge historical professional and power demarcations between the nursing and medical professions. While there were a number of significant learning outcomes highlighting the complex and chaotic nature of hospital settings, the need for a ‘containing’ leadership presence, and the importance of nurturing team collaborations in hospital settings, the study found that clinicians had difficulty implementing the evidence-based approach. The reasons they cited included: confusion surrounding the role, meaning and application of evidence in the ‘real world’; resentment due to a failure to acknowledge forms of knowledge that did not fit into the language of randomised control trials; feelings of marginalisation associated with this experience; as well as organisational and systemic barriers that impacted on their capacity to collect and follow evidence-based guidelines (Piterman & Anderson, 2002)².

If evidence-based practice is to be embraced, it must be meaningful to clinicians. What constitutes evidence needs to be unpacked in a way that moves the debate forward. This, however, is difficult in the current culture surrounding evidence, which provides little opportunity for such an exploration.

Myth surrounding evidence-based practice

I now turn my attention to the revisionism in medicine that the idealisation of rationality and the myth surrounding evidence-based practice has created. Idealisation of evidence-based practice blurs its capacity to be an effective tool assisting the health care system to solve problems. As a tool evidence is vulnerable and imperfect. It makes mistakes and is applicable only in certain situations. We only have to look at the current debate regarding the use of Hormone Replacement Therapies³ to understand that what constitutes evidence today may not be evidence tomorrow.

Yet the rhetoric of evidence as truth is increasingly informing and directing public health policy and practice, stymieing debate and creative potential. Practitioners who resist proposals to define their day-to-day practice according to the tenets of clinical epidemiology have been treated as recalcitrant luddites (Charlton, 1997). Moreover, the medico-legal implications of not following evidence have created well-founded anxiety. Publicity surrounding medical malpractice and ‘bad’ doctors has dented the confidence of practitioners and rendered them more vulnerable to accusations of resistance (Donaldson 1994 in Charlton, 1997).

Evidence-based practice feeds into the managerialist craving for explicitness concerning method and measurement. Explicitness enables measurement and control. Its corollary is that what cannot be measured cannot be managed and therefore has no place. Aspects of psychiatry, namely relational psychotherapies have been undermined in the public system because they are unable to conform to objective measurements (Halasz, 1994; Leeder & Rychetnik, 2001). ‘Empirical science cannot measure the dimensions of consciousness and its disturbance, subjective experiences, empathy and personal meaning diminishing the standing of clinical psychiatry’ (Halasz, 1994, p 12). Values are separated from so-called facts and rendered as subservient, if considered at all. To the extent that there is some acknowledgement of the understanding gained from the doctor patient relationship, the ranking of the different sources of evidence - randomised control trials being at the top and clinical intuition at the bottom - is a powerful statement about whose evidence prevails and the insights that potentially may be silenced (Leeder & Rychetnik, 2001).

The outcome is a dichotomous scenario where evidence-based practice is juxtaposed against some concept of lesser or non-evidence-based practice. This artificial schism obscures excellence in clinical practice (Greenhalgh, 1996; Miles et al., 1997). Moreover, it presupposes that medicine did not have a frame and structure; that there was no evidence through observation, case study, clinical knowledge, critical analysis or peer review - ‘that it was previously based on direct communication with God or tossing a coin’ (Fowler in Charlton, 1997, p 91).

Underpinning this rhetoric is the (fallacious) argument that evidence-based practice is scientific and therefore constitutes truth. While my paper does not enter into the realm of philosophy of science, I need to refute both propositions. Evidence derived from epidemiological knowledge renders it neither science nor truth. There exists a peer-reviewed literature that disqualifies attempts to align evidence obtained from randomised control trials with scientific practice. This literature base contends that epidemiology is a statistical tool and useful servant in the pursuit of science, rather than a science in its own right. Epidemiological outcomes are statistical outcomes, not scientific outcomes. To constitute science the information obtained from randomised control trials requires careful interpretation and a contextual base (Charlton, 1997; Miles, 1997; Shahar, 1997). Popper’s (Popper, 1966) immense contribution to the philosophy of knowledge was to show that scientific theories could never be verified only falsified. Indeed the ability of a theory to be falsified is what qualifies it as scientific. To the extent that the epidemiological knowledge does have a scientific basis, its contribution is at most as an assertion, a conjecture, and a working hypothesis. Evidence may in fact be true, but it is not necessarily so. Evidence in medicine is provisional and capable of being overturned, modified, refuted or superseded by better evidence (Soros, 2003; Shahar, 1997). No one is really certain how to apply the result of trials to the individual case. Even if the medication has been rigorously evaluated in top quality trials, it is extremely difficult to predict how the drug will affect any particular individual (Moynihan, 1998). As Little argues ‘all the precision in the world only allows us to say you have this or that chance of the operation being a success’ (Little in Moynihan, 1998, p 239).

Health care is negotiated and navigated in an open system and needs to accommodate powerful influences, which are interdependent and unpredictable, irrational and unconscious. While we are offered a number of epistemological explanations that abandon narrow reductionist approaches to define excellence in clinical care, there exist other seemingly more powerful irrational forces that are responsible for the current scenario in which evidence-based practice has become idealised. Whether driven by arrogance, ignorance or strategic blindness, scientism and totalitarianism of thought result in the abandonment of critical reasoning, creating circumstances for the manipulation of evidence-based practice to serve purposes that are beyond its capacity, ultimately undermining its potential value. True science (as opposed to scientism) accommodates methodology, acknowledges context, and incorporates values.

Evidence as a political tool

I now turn my attention to the consequences of idealisation and the use of evidence-based practice as a tool to serve power interests and agendas. Evidence-based practice has become a tool of governments to monitor and control medical practice. Public health in Australia is increasingly relying on evidence-based approaches following the trend in the US health sector and the UK public health to use evidence-based practice to make purchasing decisions and determine funding priorities with contractors. While it is commendable that governments and private insurers contain, and even cut costs by reducing unnecessary expenditure on medications, procedures and tests, and direct resources to areas of the health system that are in genuine need, difficulties arise when the criteria of evidence are disconnected from reality and assume a deterministic and mechanistic view of human beings and their relationships. Lack of evidence does not necessarily constitute lack of efficacy. Nor do mechanistic concepts of efficiency guarantee efficacy. Evidence defined from a narrow reductionist perspective is not underpinned by scientific rationale. Its failure to incorporate valid perspectives, including an adequate regard for context and consumer outcomes, can lead to ill-advised purchasing and rationing decisions (Stradling & Davies, 1997; Leeder & Rychetnik, 2001).

To the extent that the ‘reduce and resolve’ (Pselk & Greenhalgh, 2001; Pselk &Wilson, 2001) view of evidence becomes idealised, truth becomes a political construct paving the way for the entry of political agendas. When evidence becomes politicised, its ethical basis is potentially undermined in the service of other agendas, creating a climate for the importation of irregular and perverse ideologies and practices under the banner of evidence. Stephen Leeder in ‘Ethics and Evidence Based Medicine’ refers to the interdependent connections between knowledge and power. He cites the French philosopher Michel Foucault, who wrote of discourses that operate in society to create ‘regimes of truth’ and power, and the ability of those holding political ascendancy and power to filter knowledge and order to create inferior forms of knowledge that do not fit into the ascendant paradigm in the name of their ‘gold standard’ knowledge. The power of the elite derives, in part, from their connection to powerful institutions which endorse the definition of ‘gold standard’ knowledge and evidence (Leeder & Rychetnik, 2001) thereby perpetuating its idealisation.

The corporate sector is one such power base and interest group. Aligned with medical schools, research institutes and governments it has been instrumental in influencing the nature of evidence and the direction of public policy. The corporate sector is driven largely by a profit imperative and return on investment. This imperative may not always coincide with a social and ethical agenda. Drug companies are involved in creating evidence, as in the case of SmithKline Beecham funding the preparation of guidelines for the treatment of panic disorder as part of a marketing exercise for its antidepressant ‘Aropax’ (Moynihan, 1998).

When pharmaceutical companies fund research there is a concern that the evidence they generate may be biased in favour of the drug remedies they are selling. Politicisation creates the potential for distortion leading to a situation where only the evidence that fits into the politicised agenda is published. Trials producing a so-called ‘negative result’ are less likely to be published than those producing a positive finding, raising the validity of the scientific evidence and an overestimation of the degree of benefit (Moynihan, 2001; Leeder & Rychetnik, 2001; Zwitter, 2001). This is exacerbated by ties that exist between drug companies and researchers. As Angell (2000) points out ‘there is considerable evidence that researchers with ties to drug companies are indeed more likely to report results that are favourable to the products of those companies than research without such ties’. For example, psychiatrists with links to drug companies selling antidepressants are less likely to hold an independent view regarding treatment of depression (Moynihan & Sweet, 2000).

Further examples revealing the consequences of politicisation have been published in the British Medical Journal. I cite the extensive research undertaken by Moynihan who has sought to expose the brittle nature of evidence when links exist between drug companies and research institutions. ‘Twisted together like the snake and the staff, doctors and drug companies have become entangled in a web of interactions as controversial as they are ubiquitous’ (Moynihan, 2003a). The results of a drug trial, borne out of a relationship between Pharmacia and research institutions, were published in the Journal of the American Medical Association (JAMA) and concluded that based on epidemiological evidence the drug Celebrex used for the treatment of arthritis caused fewer side effects than other drugs. The authors, who were funded by the drug company Pharmacia, chose not to publish the results of the full study as these were less favourable than results obtained from the first six months of the study (when negative side effects did not have time to emerge). After reviewing the full study, the Food and Drug Administration’s arthritis advisory committee concluded that Celebrex offers no proven safety advantage over the two older drugs in reducing the risk of ulcer complications (Moynihan, 2003e).

Another study, published in the British Medical Journal (BMJ) (Enstrom & Kabat, 2003) by the University of California’s School of Public health titled ‘Environmental tobacco smoke and tobacco related mortality in a prospective study of Californians, 1960-98’ was funded by the tobacco industry. It presented randomised controlled findings that passive smoking will not kill you, give you heart disease or lung cancer (outcomes that directly contradict the International Agency for Research on Cancer, which is an arm of the World Health Organisation). In their paper Enstrom and Kabat argue that because of the limitations of past epidemiological studies, one cannot establish causality between passive smoking and lung cancer and ‘the association between environmental tobacco smoke and tobacco related diseases is still controversial’. They designed another epidemiological study, superior in rigour, which disproves past such studies and arrives at the conclusion that ‘the association between exposure to environmental tobacco smoke and coronary heart disease and lung cancer may be considerably weaker than generally believed’, a different outcome to past studies. The BMJ has been quick to publish responses to the article. ’If the understanding of the facts on second hand smoke had indeed changed then the tobacco control community needs to be prepared to rethink. But it doesn't look like the facts have changed at all, just that the BMJ has let a shoddy study assume the status of 'facts'’ (Bates, 2003).

The corporate agenda is not averse to what Ray Moynihan (2002, 2003c) refers to as ‘the making of diseases’ and the ‘selling of sickness’, exemplified when drug companies invented a condition called ‘female sexual dysfunction’ and persuaded researchers with financial links to the drug industry to exaggerate the prevalence of female sexual problems and create what Moynihan (2003c) referred to as the ‘freshest, clearest, example’ that we have of the corporate sponsored creation of a disease (Moynihan 2003c, p 45). Halasz et al. (2002) in Cries Unheard has examined the phenomenon of Attention Deficit Hyperactivity Disorder (ADHD) and claims that rationalist approaches motivated by quick fix solutions have resulted in misdiagnosis and the administration of medication on the basis of what he calls non-rational prescribing, which ignores a vast corpus of knowledge: attachment theory, its psychodynamics and the uncovering of its neurobiological foundations’ (Halasz, 2003).

Psychoanalytical approaches to understanding

I will now use the psychoanalytical constructs of splitting and projection, projective identification part and whole objectives to explore two working hypotheses around the dynamics discussed in this paper. First, evidence-based practice as a defence against uncertainty and ambiguity; and second, and connected, evidence based practice as an envious attack on the doctor patient relationship.

Deification of evidence-based practice as a rescue package, and collusion with its underlying tenets may well be a defence against the uncertainty of an increasingly unpredictable world, creating a fantasy world of certainty framed in the language of rationality, practicality, technology and specialisation. We are led to believe that we can control the uncontrollable, by framing society and its relationships in a brave-new-world metaphor of man as machine through a process of reductionism and numerical probability. (The hip in bed twenty-two, ward four has a 60% chance of success.) Psychic defence mechanisms of denial, splitting, projective identification and scapegoating are mobilised in an attempt to protect this fantasy world by undermining the road to understanding through the experience of uncertainty (and hence reality).

The literature provides us with a number of frames for exploring the phenomenon of idealisation and the concomitant splitting at an individual, organisational and societal level. Klein (1975) described a paranoid-schizoid state, as a state of mental disintegration predominated by splitting, projective mechanisms and part object relations, all of which circumvent the capacity for whole objects and instead only allow for selected aspects of thinking and being to be deployed (defences of order and rigidity which we defend against by splitting). The phenomena of splitting, and scapegoating, are consistent with what Bion (1961) described as basic assumption dependence, identifiable by a ‘a belief in the omnipotence or omniscience of some one member of the group’ (Bion 1961 in White, 1997, p 165) but as Jean White suggests, ‘can equally be a thraldom to an ideology’ (White, 1997, p 65). Howard Schwartz (1990) provides us with a concept of an organisational ideal, which is an attempt by individuals to cope with the exigencies of an imperfect world by splitting off what is difficult and uncontrollable. Lawrence (1998) provides an interpretation for the observed phenomena in which participants in contemporary organisations respond to uncertainty and an ambiguous environment by holding what he refers to as a ‘totalitarian state of mind’. This is a social system of defence against the fear and insecurity experienced, which circumvents the capacity for whole objects and instead only allows for selected aspects of thinking and being to be deployed. These can only be ‘calculative, goal orientated, rational - in short, essentially schizoid’ (Lawrence, 1998, p 8).

Where evidence-based medicine reigns supreme, its position as master rather than servant impacts on the dynamics of the doctor patient relationship. Idealisation in its extreme robs both patient and clinician of the dignity of their positions - the patient is no longer dependent on his/her doctor in the same way, if at all. The primacy of evidence renders dependence on one’s physician as secondary – what can the doctor offer when one has free access to a superior knowledge status that can be readily downloaded via the internet. Moreover, the dignity of the patients’ status is undermined by downgrading the emotional and ambiguous aspects of what constitutes medicine - to be ill, to be vulnerable, to be dependent, and in short, the right to be human, as opposed to a fantasy construct of a ‘rational citizen’ or ‘client’ operating in a world of perfect knowledge.

The doctor is robbed of the dignity of professional integrity - creativity, subjective understandings, emotional intelligence, all of which constitute the right to engage with humanity and create meaning, understanding, and healing through connection. While the tacit dimension of human knowing (Polanyi, 1983) cannot always be made explicit in the same way as numerical data, it is a paramount tool and the necessary bridge between the realm of population-based data and the uniqueness of the individual case. To relinquish the tacit dimension for a formula that reduces the medical encounter to a step-by-step assembly line approach, is to irrevocably change the role of clinician and alter the creative dynamic of the patient doctor relationship.

One’s humanity as a clinician, rather than being intrinsic to the practice of medicine, is relegated to an optional extra and leads to, what Chapman (1999) refers to as task corruption and task hatred, resulting in its subsequent ‘amputation’. A health system that splits off its humanity splits off the very essence of medicine, what Hutton (1997) refers to as the ‘core technology’ of health care, and what Pelligrino (in Buetow, 2002, p 105) refers to as ‘the end, the telos and purpose of the clinical encounter’. The medical consultation constitutes the ‘essential unit of medical practice…. the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts’ (Spence in Charlton, 1997, p 96). Trust is intrinsic to facilitate the creative enterprise referred to as the clinical relationship.

This is difficult in a world which denies emotion and connectedness as reflected in the pejorative connotations of the phrase ‘the dependency culture’ (Carr, 2001; White, 1997) to connote a society which acknowledges interdependent relations. Dependency (on one’s medical practitioner) is an irrelevant indulgence in a fantasy world of certainty and simplicity, where so called evidence information, touting as scientific knowledge, is freely available to be downloaded by the rational and informed consumer. This so-called democratisation of knowledge threatens to render the current status of medicine obsolete, impacting on the way health care knowledge is defined, practice and competency is determined, and practitioners trained. What is the essence of the doctor patient consult in circumstances where humanity, dependence and trust can fall off the edge? Without these elements there can be no relationship. Denuded of humanity, the primary task of medicine is perverted.

The doctor patient relationship provides the space for this creative endeavour. The trend towards reductionism and simplification could be interpreted as an envious attack on this creative dyad, congruent with avoidance of the ‘depressive’ position in which whole-object relations, concern for the object and integration predominate to enable the system to contain the ambiguities of existence - we can love and hate the same object (Young, 1994; Stacey, 1997). The inability to mediate both terrains is the inability to be witness to the relationship, to stand outside the creative couple, to resolve the Oedipal complex and hence grow up emotionally (Chasseguet-Smirgel in Young, 1994).

If we are to maintain the integrity of medical practice, then we need to relinquish the part object, man as machine metaphor, and move to a position where the object can be accommodated as a whole, embracing ‘the ghost of the machine’ (Koestler in Halasz, 1994) thereby enabling the concept of whole body medicine. While the trend towards specialisation and technology provides a useful tool to enhance aspects of medical practice, this is only part of the medical experience. The challenge is to hold onto the medical encounter as a whole object. This requires the capacity to resist the desire for elegance and closure and accommodate complexity, integrate competing positions, and accept fallibility and uncertainty – indeed a level of maturity such as that required in holding the depressive position. Klein associated the occupation of the depressive space as the basis for creative activity, as it is only from the depressive position that we can experience the guilt that drives reparation, the source of all creative behaviour (Stacey, 1997; Segal, 1955). Britton describes how the disillusion of Oedipal illusion is necessary for symbolic and creative thought, the capacity for containment, and that which is being contained, congruent with the depressive position. ‘We resolve the Oedipus complex by working through the depressive position and the depressive position by working through the Oedipus complex' (Britton, 1989, p 35). Idealisation of evidence-based practice reflects a failure to emerge from the Oedipal crucible, a failure to deal with complexity and instead maintain the fantasy of the universality of an idea (Sacks, 2002), hence an inability to allow for the emergence of a form of knowledge and understanding that is separate and other and has a worthwhile place outside evidence-based practice. It is only from the depressive position that the existence of a view of the world outside that of the idealised evidence-based construct can be tolerated and embraced without the need to destroy it.

Conclusion

Evidence-based practice alone is not a sufficient basis for providing meaning to one’s role and practice as a clinician. Moreover, when idealised it marginalizes and undermines the clinical relationship. While evidence-based practice has its place as a useful toolkit for measuring, when it becomes idealised and politicised, bifurcation results impacting on the essence of medical practice and usurping the potential benefits that evidence-based practice can bring. To embrace the integration of individual clinical experience with the best available evidence from systematic research is a challenge. Accommodating reflection and reflexive practice into day-to-day decision-making, rather than eschewing that which does not fit into the idealisation, requires confronting the reality of ‘uncertainty’ and ‘not knowing’, and creating the opportunity for exploration and discovery. Undue emphasis on practicality, immediacy, technology, and statistical numeracy is a defence against such discovery. Evidence-based (best) practice in medicine needs to be viewed in the context of the health care organisation as a complex system. Simplistic, unidirectional approaches to evidence will not provide effective foundations for practice. Indeed they create a fertile climate for the entry of political and other diversionary agendas. Complex systems need to be underpinned by complex foundations that incorporate not only the evidence from randomised control trials but dimensions of evidence that include the scientific, theoretic, practical, expert, judicial, and ethical (Buetow, 2002) to create a place that ‘can combine the ‘empirical’ objective, the personal ‘subjective’ and ‘transcendent’ truths (Halasz, 1994). It is only through this process that some rational (as opposed to rationalist) discussion can take place and projections reviewed and taken back allowing evidence-based practice to take its rightful place as a statistical tool used to enhance the practice of medicine.

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Notes

¹ The Clinical Support Systems Program (CSSP) is an initiative of the Royal Australasian College of Physicians (the College) funded by the Commonwealth Department of Health and Aged Care (the Commonwealth), the Victorian Department of Human Services (DHS) and the New South Wales (NSW) Department of Health.

The College has developed a model that integrates the methodologies of clinical practice improvement (CPI) and evidence based medicine (EBM) to enable clinicians to embed best practice routinely in clinical care.

² ‘Evidence-based medicine is unreal. You cannot constrain everything in a controlled experiment’. (Physician)

‘Although evidence says this is best practice, how do you apply it in reality when you do not have resources’? (Nurse)

‘The issue of evidence-based practice has had a rebirth. There has been a resurgence of evidence-based practice. I am committed to rigorous scientific evidence, objectively demonstrated outcome, but in reality it is very challenging to apply it. The biggest challenge is marrying reality and skills and bums on seats to get them through the system. There is also a perceived conflict between evidence-based practice and craft knowledge of our practice. We know something works even though we do not have the numbers. It’s about cumulative experience. Although there are some fantastic randomised control trials that demonstrate that evidence-based principles are necessary and important, it’s even more important to demonstrate usefulness and worthiness of what we do. But it’s paramount politically for us to go down the evidence-based practice path because of accountability issues’. (Speech therapist)

‘We are continually in an environment that says best outcome is based on evidence. But this has been misinterpreted. Just because you have evidence it does not mean you have best practice. You need to interpret evidence and use clinical judgement’. (Physician)

‘Once people have had a go at constructing the evidence, applying the evidence, they will see it’s flawed. We need a proper place to have the discussion of what evidence-based medicine means. It’s only through this process that we will acquire knowledge’. (Physician)

‘Stroke management is a controversial matter and involves questioning applicability of evidence in the real world, what can be referred to as reality-based evidence. There are some controversies in stroke management and if we are going a step further we need to discuss them’. (Physician)

‘I am against cookbook medicine. Guidelines do not take into account all situations’. (Physician)

‘There may be more than one level of evidence. Qualitative evidence is useful. Most health care workers are put off by evidence-based practice because the evidence that is recognised is limited to level 1’. (Occupational therapist)

‘Why don’t people implement evidence? It’s difficult to implement because evidence utilised is not necessarily relevant’. (Occupational therapist)

‘Evidence-based medicine is about randomised control trials. This is about qualitative work. Randomised control trials are not real world. They cannot pick up the nuances. We are not going to find Level 1 on consumer evidence. It’s important to acknowledge qualitative research and the issues. Evidence-based evidence tends towards the use of IT and epidemiology. It’s one model. It’s an ascendant model. It’s a scientific model. What they call evidence-based evidence is scientific evidence. It’s scientific excellence and merit. But that is one paradigm’. (Consumer representative)

³ Series of articles in Journal of the American Medical Association Sappa N. (2002) Hormone Therapy Falls out of Favor Science News on Line Week of July 27, 2002; Vol. 162, No. 4

Chen, C.-L., et al. 2002. Hormone replacement therapy in relation to breast cancer. Journal of the American Medical Association 287 (Feb. 13), pp 734-741. Available at http://jama.ama-assn.org/issues/v287n6/abs/joc10761.html.

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Hulley, S., et al. 2002. Noncardiovascular disease outcomes during 6.8 years of hormone therapy. Journal of the American Medical Association 288 (July 3), pp 58-66. Available at http://jama.ama-assn.org/issues/v288n1/ffull/joc20522.html.

Lacey, J.V., et al. 2002. Menopausal hormone replacement therapy and risk of ovarian cancer. Journal of the American Medical Association 288 (July 17), pp 334-341. Abstract available at http://jama.ama-assn.org/issues/v288n3/abs/joc20074.html.

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Writing Group for the Women's Health Initiative Investigators. 2002. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Journal of the American Medical Association 288 (July 17), pp 321-333. Available at http://jama.ama-assn.org/issues/v288n3/ffull/joc21036.html.

Bio and contact detail

Dr. Hannah Piterman is Director of the Centre for Organisation Evaluation and Change at Monash Institute of Health Services Research, Monash University Melbourne. She brings twenty years of expertise as an economist, sociotechnical researcher and change management consultant assisting organisations across private and public sectors solve problems, make decisions about future direction, and enhance the management of the change. She has conducted organisational reviews, facilitated the management of change and developed leadership programs across a number of sectors including health mining, food, media and tertiary education. In recent years her focus has been in the area of healthcare reform where she is working in change management via a collaborative action research evaluation methodology with large-scale complex national projects in primary and community health, men’s sexual and reproductive health, mental health and acute health. Her interest in the area of leadership development involves working with individuals and groups to explore themes and issues around role concept and leadership. She works in a mentoring capacity on a one to one basis and with groups. She has developed a number of leadership programs including the University of Melbourne Program ‘Leading in a Changing Environment’.

email: hannah.piterman@med.monash.edu.au or

email: mhumanre@bigpond.net.au