How to integrate different sources of knowledge
Despite the success of guidelines in providing more rational and
effective health care, the use of guidelines has recently been
criticized as being impersonal and leaving little room for expertise of
the clinician and the patients views and preferences9.
Clinical expertise might enrich scientific evidence as clinicians know
what actually works in practice. The experiential knowledge of patients
could improve the quality of care because patients bring in the unique
experience how to life with a disorder10. The
combination of scientific evidence with clinical expertise and patients
preferences also might stimulate the acceptability and implementation of
guidelines11.
However, no coherent method has been developed thus far to integrate
scientific evidence with clinical expertise and experiential knowledge.
For scientific evidence the GRADE system12 has been
developed, a common, sensible and transparent approach to grade quality
(or certainty) of evidence and strength of recommendations. For research
on clinical expertise and experiential knowledge different research
methods are used (participatory research, qualitative research,
narratives), but their scientific base is not as strong as in evidence
based medicine. Furthermore, a procedure how to weigh each domain of
knowledge is currently lacking.
The developmental process of the standard of care for depressive
disorders showed how clinical expertise and experiential knowledge
supplemented scientific evidence in cases where evidence was weak or
lacking. Interesting here is the adoption of art therapies in this
standard of care although the evidence for the efficacy of art therapies
is currently lacking. Psycho-analytic psychotherapy is added as an
optional psychotherapeutic method, despite a weak scientific base,
because of the strong appreciation of professionals for this form of
psychotherapy, at least in our country. Methods to assemble experiential
knowledge were a survey among members of the consumers organization and
a focus group meeting. Consensus meetings in the working committee were
used to weight the recommendations that came from the different
perspectives and that method proved effective but is of course not fully
transparent. It is important to develop an general accepted procedure to
integrate scientific evidence, clinical expertise and experiential
knowledge in practice guidelines.