A Doctor's Order : The Dutch Case of Evidence-Based Medicine (1970-2015)

Abstract

In the early 1990s, a new concept was coined: ‘evidence-based medicine’ (EBM). After a remarkably short time, EBM was virtually all-pervasive in medicine and healthcare throughout the world – with the Netherlands at the forefront. How should we understand this new phenomenon? And: what actually is evidence-based medicine?

These questions are all the more relevant because, on reflection, EBM proves to be an elusive, multifaceted entity. Various stakeholders sometimes give widely differing meanings to it, and EBM itself has undergone a number of substantial changes over the course of time. It is therefore the objective of this study to arrive at an answer to the aforementioned questions from a historical perspective. From its history it appears that the phenomenon of EBM maybe characterised as ‘A Doctor’s Order’ – the title of this dissertation, which refers to two essential aspects of evidence-based medicine.

The first aspect is contained in the title word ‘order’, which refers to EBM as a mechanism of control – an instrument for ‘ordering’ (regulating, formalising, rationalising, standardising) medical practice. The rise of EBM in medicine and healthcare is often analysed (referring to the work of Theodore Porter) as a professional response to external societal pressure. The argument runs as follows: when public distrust towards medicine grew, the field was in need of an instrument which would guarantee transparency and accountability – and hence trust. This places the rise of EBM keenly in the context of the late twentieth century, when, indeed, medicine faced increasing pressures, as a result of the burgeoning costs of the welfare state necessitating cutbacks, criticisms of ‘medicalisation’, and the increasing uncertainty of physicians who were confronted with an ever more complex practice and an unmanageable explosion of medical knowledge.

Yet, Porter’s interpretive framework is too instrumental and anonymous to satisfyingly characterize EBM. In the description of the ‘Dutch Case of EBM’ it emerges clearly how great and sometimes decisive the role of personal factors was in the rise of clinical epidemiology and evidence-based medicine in the Netherlands. In order to do justice to this, the designation ‘A Doctor’s’ in the title refers to a second aspect of EBM: the major input of individuals or small groups of medical professionals, who the historian Marks would refer to as ‘therapeutic reformers’ – thus introducing human agency. Marks typifies the ‘therapeutic reformers’ as a ‘political community’. It is extraordinarily clarifying to also conceptualise the Dutch EBM movement as a political reform movement of sorts, largely consisting of doctors who practiced ‘future rhetoric’ and carried out ‘missionary work’ on behalf of EBM.

This ‘reform movement ’significantly contributed to ‘abolition medicine’, to the adaptation to the ‘information explosion’ in medicine and possibly to a mentality change within the medical profession. At the same time, EBM has nowhere near brought the ‘revolution’ or ‘paradigm shift’ that was once proclaimed. In fact, if the medical profession wants to prevent governments and insurers from using EBM in an undesirable manner to impose bureaucratic rules, then EBM must be put into more modest perspective, acknowledging its limitations.