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The medical research cycle is often initiated by clinical observation and epidemiological study which identify associations between clinical manifestations and biological or environmental factors. Associations do not indicate cause but generate hypotheses for focused research. As an aspiring academic paediatrician, I focused on hypothesis-driven research to investigate the early-life causes, consequences and management of asthma and related allergic diseases. Subsequent controlled intervention trials, despite being published in high-impact journals with evidence which should have modified clinical practice for patient benefit, did not improve patient outcomes. I, like many others, thought that putting knowledge into practice would be achieved by generating clinical guidelines. They were initially ‘expert opinion’ driven and rapidly gained popularity. Guidelines are now generated by many agencies for many medical disorders and are much more appropriately dictated by an evidence-based approach employing systematic review and meta-analysis.1
Guideline proliferation has overwhelmed clinicians. They are often large documents detailing the evidence base but often fail to account for patient experience and the practicalities of application. It is, therefore, not surprising that they have not improved outcomes for patients despite having high citation impact. It is worthwhile requoting the Sackett definition of evidence-based medicine: ‘The conscientious explicit and judicious use of current evidence in making decisions about the care of individual patients requires the integration of clinical expertise, external evidence and patient values and expectations’.2 Sadly, most guideline groups do not include patients and fail to address their values and expectations. For …
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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