In the ever-evolving landscape of healthcare, we are often confined to established practices, benchmarking against an evidence base that may not always be as robust as we assume. Last year, while working on clinical reviews and investigations, it reinforced a critical flaw in our approach: the statistical mean, often considered a benchmark, does not apply in most contexts. By studying the outliers, we can gain a deeper understanding and possibly unearth more effective practices.

Our healthcare systems and the people within them cannot be neatly categorised into rigid structures. This realisation is not just academic; it impacts real lives and possibly has led to the decline of quality within our systems.

The narrative presented in Giovanni D. Tebala’s “The Emperor’s New Clothes: a Critical Appraisal of Evidence-based Medicine” resonates deeply with this sentiment. Tebala’s work, along with the drama ‘Mr. Bates and The Post Office’, shines a light on how organisational structures often create an infrastructure blind to the truth, reinforcing falsehoods.

Read Tebala’s Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6158662/#:~:text=The%20Emperor%20will%20be%20our,up%2Dto%2Ddate%20medicine.

In the realm of healthcare, complexity often induces a sense of panic, stemming from a deviation from the norm. This deviation can lead to a fear of rejection among healthcare professionals. However, it is precisely these deviations that can lead to breakthroughs and improvements in patient care.

The call to bring back the patient and the practitioner to the centre of the decision-making process, as advocated by Tebala, is a step in the right direction. Clinical choices should be based on a triad: the evidence base, the personal experience of the practitioner, and the expectations of the patient. This approach aligns well with the latest guidelines on decision-making from the General Medical Council, emphasising the importance of shared decision-making and valid consent in patient centred care.

General Medical Council’s Guidelines on Decision Making and Consent: https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/decision-making-and-consent

This brings me to my propositions for a shift in mindset and practice:

• Reviewing Outliers: We need to focus more on outliers than on the statistical mean. This approach can reveal insights overlooked in average data.
• Language in Policies and Records: The language used in our policies, procedures, and patient records should reflect shared decision-making, prioritising humanity over the technical and managerialism.
• Healthcare Innovation: We must explore new ways of understanding and doing things, stepping outside our comfort zones and traditional methodologies.

The pivot of this decision-making process is the practitioner, who must evaluate and interpret evidence, from basic research to meta-analyses, in the context of their experience. This requires an understanding and judgment that goes beyond mechanical rule-following. It’s about engaging in meaningful conversations with patients, ensuring that decisions are made collaboratively.

Evidence Based Medicine, a movement in crisis: https://www.bmj.com/content/348/bmj.g3725

In our teams, we need to foster lateral thinking. We should explore how we construct our understanding, how we co-create meaning with others, and how this reflects in the broader healthcare ecosystem. This goes beyond the rigidity of traditional Evidence-Based Medicine frameworks. While ensuring patient safety is paramount, to improve clinical outcomes, a shift in mindset is essential.

This approach forms a new evidence base, one that goes beyond simple triangulation. It celebrates qualitative research, narrative medicine, and case reviews, creating more equality in the evidence hierarchy.

Rita Charon’s work in narrative medicine could provide valuable insights here. By emphasising the importance of patient stories and experiences, we can understand healthcare from a more holistic perspective. This approach aligns with the concept of shared decision-making and recognises the individuality of each patient’s journey.

This is not just about changing practices; it’s about transforming the culture of healthcare.

In conclusion, our duty in healthcare is not just to follow established protocols, but to continuously question and refine them. By focusing on the outliers, using language that emphasises humanity, and adopting a more holistic approach to decision-making, we can improve patient care and outcomes. It’s time we see beyond the system and reconnect with the obvious – the well-being of our patients and those who care for them.