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Fam Pract Manag. 2002;9(4):12

Two potent influences in health care today are evidence-based medicine and rapid-cycle quality improvement – EBM and QI. It’s fascinating to me that the two should be ascendent at the same time, since in some respects they seem to get along about as well as the Montagues and the Capulets.

On one hand, there’s evidence-based medicine. Even evidence from a randomized controlled trial is not enough for EBM. It is most at home in the world of systematic meta-analyses, where countless randomized trials and cohort studies and whatnot are boiled down to a small quantity of thick stock. EBM is happy when what’s left of the work of myriad researchers is a single thought: “It’s a pretty good bet that x is true” – or even, “Despite all the research done to date, we don’t know whether y is true or false.” EBM reclines happily on a stone floor of carefully controlled research and strict logic.

QI, on the other hand, attempts to make its home in uncontrolled daily life. It not only shuns meta-analysis; it gets by with as little analysis as it can. It doesn’t boil anything down so much as skim off what floats to the top. And it rests cheerfully on statistical cushioning soft enough to give EBM a persistent backache.

In eating the fruit of received knowledge, EBM carefully pares out all the bad spots, knowing that most of the fruit is bad spots, and is content to subsist on the meager fare that’s left. QI eats the whole fruit to keep body and soul together and is content to try to digest the bad with the good and spit out the seeds.

The clash

If you haven’t had occasion to see these two streams of thought interact in a meeting or lecture hall, it’s worth watching. Predictably, the forces of evidence begin to look a bit seasick when they understand what the forces of quality are proposing as adequate measurement of improvement. Sensing the reaction they have elicited, the forces of quality protest that we’d never improve anything if we waited to be absolutely sure of the best course. If collision is avoided, it’s because the two are traveling on parallel tracks and pass each other in the night, each having difficulty believing that anyone would head the other direction.

The problem is that we need both. Each has its own truth. Where EBM pans for gold, QI opens a sand-and-gravel business. And as valuable as gold is, gravel can be turned into roads and buildings.

Hearing voices

If you’re like many family physicians, I would guess that you live somewhere between the world of EBM and the world of QI. The voice of some medical-school professor may still reverberate in your head, preaching the gospel of the randomized trial and urging you to rely on your own careful critique of reports from the literature to shape your approach to medicine. And yet you’ve been in practice long enough to know that evidence won’t get you through a day of patients. For most of what you do, you have to rely on what at least seems to work, not what you’re certain is true.

Does the echo of the professor’s voice make you feel a little guilty? Does it make you a little more suspicious of QI than you would otherwise be? If so, I would urge you to tell him to take a break – just long enough for you to give rapid-cycle QI a thorough trial. (No, not a randomized trial.) You may be able to use it to build a road to a better practice.

If you are interested, this issue’s cover story may be a place to start. Paul Plsek’s article on developing service excellence happens to constitute a concise and extremely readable introduction to rapid-cycle improvement (see page 41). But to read it with an open mind, you’ll have to make the old guy in your head shut up. Plsek’s approach won’t take you all the way to the Truth, but it can carry you from “what seems to work” to “what works better.” How bad can that be?

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