The Gold Standard: The Challenge of Evidence-Based Medicine and Standardization in Health Care, by Stefan Timmermans and Marc Berg, Philadelphia, Pa: Temple University Press, 2003. 269 pages, softcover, $20.95.
Using evidence-based medicine as a reference point, the authors set out to explore the politics of standardization in healthcare. They analyze the pros and cons of reliance on standards and best practices in relation to creativity or its absence. Their discussion of the philosophy and rationale underlying medical best practices and of the standards developed from them is excellent and to the point. It is important not to ignore the reasons for, and the history of, performance standardization in fields other than healthcare-a relationship sometimes overlooked by students of healthcare delivery systems. Timmermans and Berg, in discussing the origins of standardization, cite the work of Frederick Taylor and his contemporaries. In reviewing the early development of medical standards and evidence-based medicine, they cite the contributions of Cochrane, Wennberg, and Sackettt.
In Chapter I, the masterful description of the emergence of the paper-based patient record and of the mechanics of medical record practices in the early part of the 20th century is absorbing. While the writers' description addresses historical development, in the experience of this reviewer, in some areas of the world medical record practices haven't changed much since mid-century.
In discussing how standards of care function, the authors address the issues of "cookbook medicine" versus reducing inappropriate variation. They try to offer alternative approaches to the polar extremes that characterize many accounts of evidence-based medicine and practice guidelines. Their presentation of the International Research Protocol and insurance reporting standards is very illuminating. The use of examples in the Chapter II section on standards as coordinating devices effectively clarifies many of the issues.
The title of the third chapter, "From Autonomy to Accountability? Clinical Practice Guidelines," says it all. In this excellent chapter, the authors explore what they call the love-hate attitude of professionals toward performance standards and clinical guidelines. They show how the use of clinical practice guidelines changes both the nature of the guidelines and the autonomy of the healthcare professional. The roles of third parties in their efforts to foster transparency and accountability are thoughtfully addressed.
In their fourth chapter, "Guidelines, Professionals, and the Production of Objectivity in Insurance Medicine," the authors address the impact of transparency, standardization, and guidelines on the performance of healthcare professionals. Using the healthcare insurance system of the Netherlands as an example, they studied physicians' reactions to the introduction of guidelines. They explore the impact of reporting on clinical decision making. An outstanding feature is the section dealing with redefining objectivity in the context of healthcare services. The impact of evidence-based medicine on medical school training and culture is the subject of the fifth chapter. The authors address the issues involved in the confrontation of evidence-based medicine with time-honored clinical judgment, and how the pragmatic human approach serves to reconcile them.
The gripping history of Thalidomide and its redemption is the basis of the chapter entitled, "Standardizing Risk." In explaining how the drug finally came to market, the authors trace the development of what they describe as, "the most stringent drug distribution system in U.S. history, the System for Thalidomide Education and Prescribing System,"(p173) or S.T.E.P.S. In an epilogue following this engrossing chapter, the authors review and summarize their observations and analyses of the rationale for and the effect of standardization efforts on clinical performance.
This eminently readable book is recommended to healthcare industry personnel and to policy makers who would be interested in a thoughtful study of the political, ethical, and functional aspects of the standardization of clinical behavior.