I enjoyed Dr Greenstone’s article, “The roots of evidence-based medicine,” as published in the October 2009 edition of the BCMJ [51:342-344]. Thank you for publishing it.
My reaction was associated with the following thoughts.
The information that humanity has used to create truth in any given decade or century has varied dramatically in its source and content: in Babylon it was the seers and priests; in ancient Greece it was the philosophers; in Roman times it was the emperor; through the Dark and Middle Ages it was mother church; and then, in the mid-1800s the scientific method entered into the mainstream, with such great minds as Newton (physics), Darwin (biology) and Freud (psychology). In medicine, Harvey (circulation), Van Lewenhock (bacteriology), and Jenner (infectious disease) each brought convincing evidence of a new reality.
It is my opinion that the evidence pendulum has moved too far toward “objective scientific and statistical evidence” and away from “common sense and good old-fashioned intuitive clinical knowledge.”
My personal experience has been this: in pre-med the evidence was that I would not even get an interview for medical school unless I achieved a 92% average; in medical school the evidence was that if I did not show up for class, behave reasonably, and pass my exams, I would not graduate; in residency the evidence was that if I did not practise medicine in the professor’s style I would be gently moved out of the program; and in the last 33 years of my medical practice the evidence has been that if I did not make myself available, treat patients and colleagues with respect and consideration, and get it right (read: save lives) most of the time, I would not achieve the level of professional and financial success that I desired.
My final thought in respect of our modern medical evidence-based world is that this concept has been hijacked by governments, hospital administrators, and the pharmaceutical and insurance industries.
I believe that the current evidence is that:
• Government believes that the cheapest drug, product, or surgical intervention is the best, and that all medical doctors are created and function equally.
• Hospital administrators believe that the shortest stay is the best (regardless of outcome) and that the only good doctor is a doctor who works for them (read hospitalist who puts the hospital’s interests first versus a hospital-associated GP who puts the patient’s interests first).
• The pharmaceutical industry believes that the most expensive and profitable drug is always the best.
• The insurance industry believes that if the “evidence” does not absolutely prove that an expensive treatment will work and, also, that cheaper treatment does not, they will not pay, or delay payment until, preferably, the patient has died and the treatment is no longer necessary.
—Ian L. Mitchell, MD
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Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
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