We like to think of evidence-based medicine (EBM) as objective, neutral and fair.

But it isn’t.
Not entirely.

Because Evidence Based Medicine (EBM) doesn’t exist in a vacuum, it exists inside systems shaped by power.

And power is uneven. Talking about power in healthcare can feel awkward. It challenges our belief that we work in systems built on equity and fairness.

But if we don’t name power, we can’t see how it shapes decisions, whose voices are heard, and ultimately what counts as “evidence.”

My perspective on this comes from moving between roles: doctor, nurse, board member, patient, and family member.

And here’s the uncomfortable truth:

• As a doctor, my voice carries authority.
• As a nurse, my relationships create richer conversations.
• As a patient, I sometimes choose silence because I do not want to be known as the professional yet as a family member, I use professional identity to influence outcomes.

Same person. Different power. Different impact.

What does power actually look like?

Power is often mistaken for hierarchy, but it is far more fluid than that. It operates across individuals, teams, organisations and systems, shifting depending on relationships, context and access.

It is rarely explicit. Instead, it appears in who sets direction, whose knowledge is valued, who controls time and resources, and who feels able to speak.

We all hold power in different ways, through action, influence, silence or resistance.

Power also exists in the gaps between people. Where connections are incomplete, those who bridge them can enable, shape or restrict what happens next. These “structural holes” are a constant feature of complex systems like healthcare.

EBM is shaped by power—whether we admit it or not

EBM relies on shared decision-making.

But shared decision-making assumes something that often isn’t true:

That power is balanced.

In reality:

• Professionals hold clinical knowledge, system familiarity, and authority
• Patients hold lived experience but have less legitimacy in decision-making spaces

The Inverse Care Law states that those who need care the most are often least likely to receive it. Not just because of access but because of other dynamics.

Patients must:

• Translate their experiences into “acceptable” language
• Fit into service categories
• Navigate complex systems

Some people are better equipped to do this than others.

Even when patients know more about their condition than professionals, their voice can still be overridden especially if they are perceived as ‘the difficult patient’ and increasingly we reference complexity but we are not sure what this is referencing.

Power imbalances suppress the patient’s voice.

We need to create mechanisms to amplify our patients voices and include the role of those with ‘lived experience’ to co-produce EBM.

Peer support is founded on a non-coercive, human rights-based approach that focuses on building relationships purposefully sharing our own experiences, and through the mutual sharing and commonality of experience, embodying hopefulness. This is underpinned by the concepts of mutuality and reciprocity and the central focus being on building trusting relationships rather than intervention.

Trust is therefore the important element of successful personalised care and being able to discuss the power dynamics to enable us to make sense of the world.

Our latest organisations embed psychological safety, so that we can share our perspectives and the knowledge gained.

Redefining what counts as knowledge

Evidence is often framed narrowly, clinical trials, guidelines and measurable outcomes. Yet it also lives in experience, in relationships, and in context.

When we overlook these forms of knowledge, evidence-based medicine becomes partial rather than whole.

Power within teams

Teams are often spoken about as if they are neutral collections of people working towards a shared goal. In reality, they are shaped by layers of power that influence how people behave, contribute and are heard.

Power sits in status, in relationships, in access to information, and in control over resources. It is not always visible, but it is always present.

You can see it in the flow of conversation and who feels able to speak, who is interrupted, whose ideas are taken forward, and who remains on the margins. These patterns are often subtle, but they shape both experience and outcomes.

When power becomes unbalanced or unacknowledged, it begins to distort how teams function. Information may be withheld, alliances form, individuals undermine one another, or difficult conversations are avoided altogether. Energy shifts away from purpose and into self-protection.

Over time, this doesn’t just affect team dynamics, it alters decision-making itself.

Organisations as power holders

At a system level, power becomes more diffuse, and often more difficult to see clearly.

Large organisations, particularly within health and social care, act as anchor institutions within their communities. Through their size and reach, they influence employment, the distribution of resources, access to services, and ultimately the wellbeing of the populations they serve.

Yet many of these organisations are operating under sustained pressure with workforce shortages, financial constraints and increasing regulatory demands. This creates a tension at the heart of the system, organisations hold significant power, but often experience themselves as constrained or reactive.

When systems feel under strain, patterns emerge. Attention turns towards immediate pressures, with a focus on managing demand rather than shaping improvement. Collaboration can give way to competition, particularly where resources are limited. Short-term performance begins to take precedence over longer-term outcomes.

In this space, the potential of the system is reduced not through lack of intent, but through the way power is experienced and enacted under pressure.

The risk of we ignore power

If we don’t understand power:

• We reinforce inequality
• We silence voices
• We create unsafe systems
• We mistake compliance for good care

And ultimately, we compromise EBM itself.

No one can give you power. Titles don’t guarantee it. Structures don’t sustain it.

Real power comes from awareness, relationships, values and behaviour. It shows in creating space for others, sharing knowledge, admitting uncertainty, challenging when needed and connecting across boundaries. It is often quiet but deeply influential.

Final thought

The admission that we don’t have all the answers isn’t weakness.

It’s one of the most powerful things we can do.