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Computerized medicine directing consultations with patients

Doctors are required to spend 60% of consultation time on the computer, an inside view.

Guidelines are transferred to forms on which the physician is to meet targets for patient falling within the guidelines.  The physician’s task become that of convincing a patient in the 70-74 year age group if their total cholesterol is above 240, that LDL above 100, their triglycerides are above  then he should be on a statin.  These guidelines, having been set up by pharma friendly organizations, and are based upon junk clinical trials funded by pharma.   Guidelines form the foundations for forms concerning treatment of patients.  This assembly-line medicine has been thus manipulated in ways that promotes pharma’s marketing objectives and consume most of the physician-patient consultation time:  estimated 60% of consultation time was spent box ticking…. quite a bit of the encounter will typically be taken up by the doctor working through a structured computer template that directs the questions to be asked, the parts of the body to be examined, and the recommended medication.” For important missing information in this pro-pharma article, read about how pharma generates our guidelines at  The so called evidence based medicine is based upon pharma’s tobacco science.

Campaign is launched to make patients the focus of evidence based medicine

BMJ 2014; 349 doi: (Published 03 July 2014)Cite this as: BMJ 2014;349:g4443

1.     Zosia Kmietowicz

Author affiliations

Doctors’ social functions have been replaced by templates and algorithms, leaving patients sidelined and overtreated, one of the architects of a new movement to put patients at the centre of evidence based medicine has said.

Clinical care has become “medicalised and bureaucratised,” said Trish Greenhalgh at the launch of the Campaign for Real EBM on 3 July at a conference organised by BioMed Central on health services research. Greenhalgh is professor of primary healthcare and dean for research impact at Queen Mary College, University of London.

Greenhalgh acknowledged the “huge importance” of evidence based guidelines. Incentivising GPs to identify and treat undiagnosed hypertension through the NHS’s Quality and Outcomes Framework (QOF) for primary care had served to prevent countless strokes[1], she said. “But add 150 more [targets] and you have taken that really good idea and killed the reactive care,” she said.

In a recent paper in The BMJ Greenhalgh and colleagues set out the background to the campaign and described what had gone wrong with evidence based medicine.1 Problems included the misappropriation of the “evidence based kitemark” by people with conflicts of interest; the ever increasing and unmanageable volumes of evidence; the patient’s voice going unheard because of the “managerialisation” of medicine; and the poor fit of guidelines with the growing number of people with multi-morbidity.

The paper described one case of a “74 year old who is put on a high dose statin because the clinician applies a fragment of a guideline uncritically and who, as a result, develops muscle pains that interfere with her hobbies and ability to exercise.” This was, the authors said, “a good example of the evidence based tail wagging the clinical dog. In such scenarios, the focus of clinical care shifts insidiously from the patient (this 74 year old woman) to the population subgroup (women aged 70 to 75) and from ends (what is the goal of investigation or treatment in this patient?) to means (how can we ensure that everyone in a defined denominator population is taking statins?).”

They said the case illustrated how “evidence based medicine has drifted in recent years from investigating and managing established disease to detecting and intervening in non-diseases. Risk assessment using ‘evidence based’ scores and algorithms (for heart disease, diabetes, cancer, and osteoporosis, for example) now occurs on an industrial scale, with scant attention to the opportunity costs or unintended human and financial consequences.”

At the campaign launch Greenhalgh said, “If patients knew how much of their consultation was driven by box ticking they would be hopping mad. We need more research about how to make the doctor listen to the patient. That needs to be the highest priority.” She added that an estimated 60% of consultation time was spent box ticking.

QOF should be scaled back “massively,” she said, although she admitted that it would be difficult to decide how that would happen.

Greenhalgh said, “Currently, when someone visits their GP or a hospital doctor, quite a bit of the encounter will typically be taken up by the doctor working through a structured computer template that directs the questions to be asked, the parts of the body to be examined, and the recommended medication. In the future, we want to be in a situation where doctor and patient collaboratively set the agenda and share decision making in a more emergent way, guided and supported by tools that both reflect best research evidence—how the average patient is likely to respond to the different treatment options—and also prompt discussion about what matters to this patient.”

She believed that applying evidence based medicine that mattered to patients would save money. “There are lots of interventions that could or might be effective but which people do not want,” she said.


Cite this as: BMJ 2014;349:g4443


Greenhalgh T, Howick J, Maskrey N, for the Evidence Based Medicine Renaissance Group. Evidence based medicine: a movement in crisis? BMJ2014;348:g3725.

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[1] The tragedy is that the 3 times more common myocardial infarction (heart attack) risk is not reduced, and the endpoint of death is increased, as well as a major reduction in quality of life including cognitive function, and the consumption of the health-care funds which entails even greater harm.  Moreover, the benefits as to reduction of stroke when measured in the number of patient needed to treat for one year for the patient population which falls within the recently lowered guidelines is over 300 patients.  Moreover typical treatment consists of a cocktail of 3 different categories of drugs. These dismal results are derived from pharma’s clinical trials which are marketing biased.  By Ms. Greenhalgh pro-drug comments, she is one of pharma’s opinion leaders.   The total lack of indication of the fundamental problem with guidelines (go to for a JAMA article on junk science used by pharma’s opinion leaders to justify guidelines) confirms Dr. Kmietowicz is pro-pharma.   

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