Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. While advocates welcome the stronger scientific foundation of such guidelines, critics fear that they will lead to "cookbook medicine." Studies show, however, that few guidelines lead to consistent changes in provider behavior. The hopes, fears, and mixed record of EBM are rooted in the traditional professional perspective of the clinician as sole decisionmaker. Multifaceted implementation strategies that take the collaborative nature of medical work into consideration promise more effective changes in clinical practice. E v i d e nc e -b a se d m e di c i n e (EBM) is commonly defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."1 The term is loosely used and can refer to anything from conducting a statistical meta-analysis of accumulated research, to promoting randomized clinical trials, to supporting uniform reporting styles for research, to a personal orientation toward critical self-evaluation. EBM was initially defined in opposition to clinical experience, but later definitions have emphasized its complementary character and have aimed to improve clinical experience with better evidence.2 One common implementation of EBM involves the use of clinical practice guidelines during medical decision making to encourage effective care. The Institute of Medicine (IOM) defines clinical guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."3 An expert committee does the work of sifting through the scientific literature for clinicians and offers coherently sequenced recommendations based on the best available evidence aimed at everyday decision-making situations. Guidelines can be applied to any aspect of clinical care: how and when to order diagnostic or screening tests, when to provide certain medical services, how these should be performed, and how long 1 8 J a n u a r y / F e b r u a r y 2 0 0 5 H i s t o r y & C o n t e x t

This article examines the career and reform agenda of Christopher Merrett as a means of evaluating the changing conditions of medical knowledge production in late seventeenth-century London. This period was characterised by increasing competition between medical practitioners, resulting from the growing consumer demand for medical commodities and services, the reduced ability of elite physicians to control medical practice, and the appearance of alternative methods of producing medical knowledge -particularly experimental methods. This competition resulted in heated exchanges between physicians, apothecaries, and virtuosi, in which Merrett played an active part. As a prominent member of both the Royal Society and the Royal College of Physicians, Merrett sought to mediate between the two institutions by introducing professional reforms designed to alleviate competition and improve medical knowledge. These reforms entailed sweeping changes to medical regulation and education that integrated the traditional reliance on Galenic principles with knowledge derived from experiment and artisanal practices. The emphasis Merrett placed on the trades suggests the important role artisanal knowledge played in his efforts to reorganise medicine and improve knowledge of bodily processes.

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