The Gold Standard: The Challenge of Evidence-Based Medicine and Standardization in Health Care (review)

This impressive book draws on a range of methodologically diverse case studies to assess the variable impact of evidence-based medicine (EBM) and standardization on medical and health-care practice. One of the two key strengths of the volume is that it locates the origins of the popularity of EBM within a broader framework of standardization, which the authors trace back to the late nineteenth and early twentieth centuries. This is not to say that medical historians have neglected standardization; rather, it is to acknowledge that the most fervent advocates of EBM are apt to characterize medical and health-care decision-making until the very recent past as uninformed and feudal. Another strength of the book is that the authors take great care to balance the dichotomous viewpoints that typify the standardization debate. Demonizers tend to regard standardization as a "McDonaldization" of medicine, whereby individual patients are dealt with in a highly generic way and health-care providers act under sets of rules that minimize the value of accumulated professional expertise. Champions of standardization, on the other hand, prefer to emphasize how it brings medicine closer to the certainties of "exact" science and, among other things, binds teachers, clinicians, and patients to a common knowledge-base. In The Gold Standard, Stefan Timmermans and Marc Berg reject polarization of this sort in favor of critical evaluation that is neither dogmatic nor overtheorized.

The opening chapter presents a discussion of the development of patient record keeping in the modern hospital. Guidelines (that is, procedural standards) form the basis of two chapters: one focuses on clinical practice guidelines and professional autonomy, predominantly in the United States and Canada, and the other looks at guidelines for insurance medicine in the Netherlands. Timmermans and Berg also consider EBM in medical education, and the standardization of the drug thalidomide in the United States in the 1990s. Because the authors' intercontinental traversal is not used for direct comparison between different health systems; because the wide array of settings—hospital management, clinical practice, insurance medicine, medical education, drug regulation—is somewhat disorienting; and because multiple methodologies—including document analysis, interviews, and participant observation—are used, the book is lent an air of "edited collection" as opposed to "coauthorship." Yet it satisfies partly because of this diversity of place, arena, and method. It demonstrates, first, the ways in which EBM and standardization have become so pervasive in the modern medical world, and second, the ripeness of the topic for multiple-method historical sociological research. The authors also deliver an introduction and epilogue that are clear and incisive, providing the reader with an unmistakable understanding of what they take standardization and EBM to mean.

The chapter on thalidomide is quite brilliant. Through the careful dissection of public debates and of the motivations of interested parties and individuals, the authors argue that there were two vital components of FDA approval of the marketing of thalidomide—or more precisely, THALIDOMID^TM (Thalidomide)—for patients with an inflammatory tissue syndrome called erythema nodosum leprosum (ENL). First was the normalization of the risk of fetal exposure; and second was the low level of control over physicians while, in stark contrast, "women's behavior [was] counseled, questioned, verified, checked, tested, rechecked, and then continuously monitored via a compliance survey" (p. 182).

Most invigorating for this reviewer was the assiduous working-through of a case study that integrated standardization in health care with theories about the unequal distribution of risk in industrial society. Nonetheless, the chapter that may be of greatest interest to readers of the Bulletin deals with the development of hospital record keeping. Timmermans and Berg concentrate on the period at the beginning of the twentieth century when the American Surgical Association initiated a Hospital Standardization Program that involved the creation of the "patient-centered record." While the chapter takes a...