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The multiple tributaries of evidence-based medicine share an emphasis on the importance of incorporating evidence from formal research in medical policies and decisions. However they differ on the extent to which they require good evidence of effectiveness before promulgating a guideline or payment policy, and they differ on the extent to which it is feasible to incorporate individual-level information in decisions. Thus, evidence-based guidelines and policies may not readily 'hybridise' with experience-based practices orientated towards ethical clinical judgement, and can lead to contradictions, contest, and unintended crises.  The most effective 'knowledge leaders' (managers and clinical leaders) use a broad range of management knowledge in their decision making, rather than just formal evidence.  Evidence-based guidelines may provide the basis for governmentality in health care and consequently play a central role in the distant governance of contemporary health care systems.