Evidence-Based Medicine (EBM)

“ . . . the politics of standards should not be located solely in the regulatory-political environment from which standards emerge but in the standards themselves. Standards are inherently political because their construction and application transform the practices in which they become embedded. They change positions of actors: altering relations of accountability, emphasizing or deemphasizing preexisting hierarchies, changing expectations of patients. . . . standardization is, paradoxically, a dynamic process of change. The implementation of clinical practice guidelines or novel nomenclatures generates action and creates new forms of life” (Timmermans & Berg, 22-23). . . . standardization is political since it inevitably reorders practices, and such reorderings have consequences that affect the position of actors (through, for example, the distribution of resources and responsibilities). The shifting relations between the health care professions, the disappearance of black hospitals, and the changing legal status the record in early-twentieth-century U.S. medicine all indicate that it would be a painful mistake to denote standardization as a mere technical issue, not worthy of sociological attention. . . . it is not too exaggerated to state that the introduction of the patient-centered record helped reconfigure the patient in early-twentieth-century U.S. medicine. The creation of the patient-centered record implied an individualization of the poor and the increased valuation of their status as patients through the granting of individual records to them” (53, 54). . . . we want to construe the activity of working with standards as an active act of allowing oneself to be transformed while at the same time transforming the standard. . . . working with guidelines is an active act because of the required proficiency. Rather than a matter for ‘mindless cooks,’ active submission appears to be a highly skillful activity” (73).