The Impossible Clinic: A Critical Sociology of Evidence-Based Medicine

In an interview with Michel Foucault titled "Questions of Method" (formally published as "The impossible prison"), Foucault spells out how he analysed the policy program and coordination of punishment and prisons. Ultimately he reminded readers that the panoptic prison and a disciplined society are impossible projects, and he explained how they persist. In this paper I take a similar objective, to show how clinical practice guidelines (CPGs) and their epistemological basis of evidence-based medicine (EBM) have a similar impossibility. This paper builds on earlier genealogical work that connects the emergence of the science of clinical epidemiology to the development and stabilization of CPGs in western medical training and practice. I explain the mechanisms by which CPGs and EBM are able to persist through an analysis of disciplinary decisions from provincial regulatory medical colleges across Canada. In each of Canada’s ten provinces, there is a professional college of physicians and surgeons that is responsible for regulating the profession and practice of medicine. Under these incorporated legal responsibilities is the privilege to self-regulate and discipline its members, and every college has a list of endorsed guidelines. I constructed a sample of 261 disciplinary decisions from anglophone medical colleges across Canada between the years of 2011-2016, inclusively. The disciplinary decisions were analysed in relation to those guidelines endorsed by the medical college. I found that colleges were using their endorsed CPGs to normalize the discursive practice of clinical judgment. I conclude by explaining that the liberal governance strategy of deresponsibilisation is the mechanism that allows for the persistence of CPGs in EBM while being directly antithetical to the goals of evidence-based healthcare, thus making their objectives an impossibility.