We have a thirst for new knowledge, and medical science is quintessentially
knowledge “in progress”. In fact, applying ‘new knowledge’ is the defining ambition in practicing Evidence Based Medicine in the 21st century. However, despite the fact that new knowledge on optimal treatment options, effective interventions and patient-centred care pathways is continuously generated, its uptake in real-life clinical practice can be slow and patchy. This is particularly obvious in the treatment of patients with schizophrenia, or first episode psychosis indicative of schizophrenia, where diagnostic and therapeutic guidelines change (and are often contradictory) and research findings (often of limited methodological strength) fail to resonate with the prescribing clinician.
This body of work is the result of an investigation into the interplay of factors which determine the use (partial use/interpret/ignore) of existing evidence and Guidelines in the clinical decision-making process to prescribe / not prescribe atypical antipsychotics as firstline treatment for schizophrenia - and other factors that contribute to clinical decisionmaking.
I have used the change in NICE guidance as a natural experiment to examine how a change in the evidence-base translates into changes in clinical practice, and have discovered that it does not consistently do so - and decision-making seems to be on a parallel trajectory.
I am arguing that this is a false dichotomy and in fact the ‘E’ in EBM is a multifaceted component - and clinical decision-making is informed by evidence, but what constitutes evidence and how is it utilised depends on very specific individual factors and it is possible to discern distinct ‘patterns’.
The implications are that guideline-makers may need to adapt, to account for different patterns of knowledge translation and utilisation, and that ‘one-size fits all’ approaches in producing and cascading clinical guidelines are no longer suitable.