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The Gold Standard

The Gold Standard: The Challenge Of Evidence-Based Medicine

Stefan Timmermans
Marc Berg
Copyright Date: 2003
Published by: Temple University Press
Pages: 280
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  • Book Info
    The Gold Standard
    Book Description:

    Few things make people react more strongly to the changes going on in health care than the word standardization. Critics shudder at the mindless sameness of standards, while supporters dream of a world in which standardized "best practices" open up a world of efficient health care delivery. The Gold Standard takes up this debate to investigate the real meaning of standardization and how it affects patients, doctors, and the institution of medicine.Showing that standards are not about less or more skills, or more or less uniformity, but rather about a redefinition of autonomy, patients, and relationships, Timmermans and Berg show instead that they are about creating new worlds of medical treatment. Cutting through the hype and fears, the authors show where the true powers of standardization lie. The Gold Standard will become a classic for students of medicine and health care policy, and will be a welcome book for anyone concerned with the future of our system of care.

    eISBN: 978-1-4399-0281-3
    Subjects: Public Health, Sociology

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Acknowledgments
    (pp. vii-x)
  4. Introduction: The Politics of Standardization
    (pp. 1-29)

    In 1991, leading international emergency medicine researchers gathered in the beautifully restored, 800-year-old Utstein Abbey on Mösterey, a small island off the southwestern Norwegian coast. In this breathtaking setting of green hills surrounded by wild seas, the international task force engaged in the very basic work of defining what counts as first aid life-saving behavior and how it should be recorded. Since the early 1960s, cardiopulmonary resuscitation (CPR) has been the principal first aid method of reviving victims of sudden death in the Western world. Whenever somebody suddenly collapsed, CPR gave any stranger the license to engage in prescribed actions...

  5. 1 Standardization in Medicine in the Twentieth Century: The Emergence of the Paper-Based Patient Record
    (pp. 30-54)

    Ordinary patients who had been admitted to one of the leading U.S. East Coast hospitals in 1900 with a broken leg might have spent some six weeks there, receive no X ray (although the equipment would often be available), and have their urine tested only at admission.² One or two entries might be found in the record of the ward to which the patients were admitted. At admission some medical history, the nature of the fracture, the result of the urine test, and the mode of treatment might have been written down in a few sentences, and several pages later...

  6. 2 Standards at Work: A Dynamic Transformation of Medicine
    (pp. 55-81)

    What is it that standards and guidelines do in health care work? What is their impact on the everyday activities of doctors, respiratory therapists, patients, administrators, researchers, and nurses? Popular accounts depict the invasion of standards in health care as a gradual stifling of work practices and the steady depletion of the lifeblood of skills, creativity, and a personalized approach. In an environment with preset rules and regulations, patients become numbers and “interact with impersonal technologies and technicians,” and health care workers bemoan the “removal of mystery or excitement” from their work lives.¹ On the other hand, many guideline and...

  7. 3 From Autonomy to Accountability? Clinical Practice Guidelines and Professionalization
    (pp. 82-116)

    Some of the “most successful”¹ and “widely accepted”² clinical practice guidelines are the CPR and ACLS protocols that detail the steps to be undertaken when someone suffers a cardiac arrest. About every eight years, the American Heart Association organizes a major conference to update these protocols. At the conference different expert groups go over the accumulated evidence, discuss clinical and ethical aspects of first aid life-saving, and formulate recommendations. When approved, these recommendations are translated into protocol changes and incorporated into training programs. Although even CPR protocols function far from perfectly,³ they approach the best of what clinical guidelines have...

  8. 4 Guidelines, Professionals, and the Production of Objectivity in Insurance Medicine
    (pp. 117-141)

    In the previous chapter, we focused on different ways in which evidence-based guidelines present themselves as double-edged swords for the professionals and professions that encounter or generate them. The same activities that may enhance the scientific image of a profession might reduce clinical autonomy; the instruments that make the profession’s decision-making processes more transparent also may make that process more vulnerable to meddling by outsiders. In this chapter, we zoom in on one specific case to investigate these issues further: the introduction of guidelines in insurance medicine in the Netherlands. We investigate how insurance physicians defined and perceived these guidelines,...

  9. 5 Evidence-Based Medicine and Learning to Doctor
    (pp. 142-165)

    Because EBM centers on information gathering and evaluation, medical educators have suggested an evidence-based curriculum and training to teach students medicine.¹ According to the American Association of Medical Colleges, 88 percent of medical schools in the United States have embraced EBM as a central feature of their curriculum, making it a “quiet educational revolution.”² Such curricula rest on a simple, yet subversive, principle: instead of relying on how experienced clinicians order them to treat patients, “students of health professions should be encouraged to ask every day, ‘What’s the evidence?’ ”³

    While advocates aim for a more uniform learning environment where...

  10. 6 Standardizing Risk: A Case Study of Thalidomide
    (pp. 166-194)

    The U.S. Food and Drug Administration (FDA) and the drug company Celgene faced a complicated and sensitive issue in the late 1990s, when they intended to introduce the drug thalidomide to the U.S. market. Currently, the drug is recognized as a promising treatment for a virtually endless list of serious, life-threatening diseases, including AIDS wasting syndrome.¹ But thalidomide has a dark and dangerous past: it was promoted in the late 1950s as a sedative and treatment for morning sickness (under different brand names; e.g., Distaval and Softenon), before scientists and physicians discovered that it caused neurotoxicity among some patients and...

  11. Epilogue: The Quest for Quality
    (pp. 195-216)

    In 2000 and 2001, the U.S. Institute of Medicine published two reports that set a new tone in the ongoing calls for health care reform. In the first report, “To Err is Human: Building a Safer Health System,” the Committee on Quality of Health Care in America claimed that medical errors (such as administering wrong drugs, or failing to execute a planned intervention) are a leading cause of death in the United States.¹ Much critique was raised against the precise figures listed and the exact definitions of error.² Yet the overall argument of the report—that the U.S. health care...

  12. Notes
    (pp. 217-242)
  13. Bibliography
    (pp. 243-264)
  14. Index
    (pp. 265-269)