Beyond EBM

Introduction The evidence-based medicine (EBM) movement has claimed to have induced and improved the production of trustworthy clinical guidelines. However, ethnographic research showed that clinicians rarely use explicit evidence from guidelines directly. Instead they draw heavily on socially shared knowledge and patterns of behaviour, called ‘mindlines’. To understand how EBM reaches its limits in producing meaningful guidance and finding what may lie beyond, this thesis explores the tensions between guidelines and mindlines from a philosophy of science perspective. Methods The approach I take to uncover these tensions is to view them as anomalies of a mature Kuhnian paradigm. Unlike most previous scholars, I chose not to study the use of guidelines in clinical practice but the guideline development process as a central means of the EBM paradigm to create decision making support for individual patients instead. The project draws on theoretical findings from a literature review of mindlines and philosophical analyses of perceptions in EBM about knowledge, reasoning and truth, which are juxtaposed and synthesised with empirical data from a digital ethnography of mindlines in virtual social networks of clinicians and an ethnography of guideline panels in the United Kingdom, Norway and the Netherlands. Results I show how mindlines have been researched and acknowledged in multiple contexts and evolved conceptually as a container for many theories of knowledge. In a critique I consider how mindlines challenge the fundamentals of EBM. Taking a Latour inspired perspective, I elicit how a changing EBM is trying to cope with the downsides of what he calls “purification”: a scientific practice of categorising and quantifying reality. I then provide insights into the challenges of EBM for guideline developers concerning ways to make inferences and integrate evidence. It highlights important issues in guideline development regarding its purpose, use and integration of different knowledges and suggests alternatives for the ...