Six 'biases' against patients and carers in evidence-based medicine.
BACKGROUND
Evidence-based medicine (EBM) is maturing from its early focus on epidemiology to embrace a wider range of disciplines and methodologies. At the heart of EBM is the patient, whose informed choices have long been recognised as paramount. However, good evidence-based care is more than choices.


CONCLUSIONS
We discuss six potential 'biases' in EBM that may inadvertently devalue the patient and carer agenda: limited patient input to research design, low status given to experience in the hierarchy of evidence, a tendency to conflate patient-centred consulting with use of decision tools; insufficient attention to power imbalances that suppress the patient's voice, over-emphasis on the clinical consultation, and focus on people who seek and obtain care (rather than the hidden denominator of those that do not seek or cannot access care). To reduce these 'biases', EBM should embrace patient involvement in research, make more systematic use of individual ('personally significant') evidence, take a more interdisciplinary and humanistic view of consultations, address unequal power dynamics in healthcare encounters, support patient communities, and address the inverse care law.
Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK. trish.greenhalgh@phc.ox.ac.uk.
Trisha
T
Greenhalgh
Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
Rosamund
R
Snow
Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
Sara
S
Ryan
Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
Sian
S
Rees
Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
Helen
H
Salisbury
D015982:Bias; D017028:Caregivers; D019317:Evidence-Based Medicine / Q000458:organization & administration*; D055317:Evidence-Based Practice / Q000458:organization & administration*; D006801:Humans; D010358:Patient Participation; D011785:Quality Assurance, Health Care; D012107:Research Design