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October 26, 2008

Strong Medicine?

Ben Goldacre’s Bad Science has had excellent reviews. Read some of them on Amazon. I also enjoyed it, but I found myself more interested by what it doesn’t say.

Sure, Dr. Goldacre does a good demolition job on homeopathy, nutritionists and media cover of MRSA by turning the laser of critical thinking and science on their claims. He also gives a good summary of the scientific approach to medicine, asserting the importance of the proper construction of medical trials with randomisation and the maintainenance of proper controls--though to those who, like me, studied science none of that is news.

Dr. Goldacre is also big supporter of evidence-based medicine, which he says has saved millions of lives. He doesn’t give any evidence for that, but we can believe it to be true. In the chapter entitled Is Mainstream Medicine Evil? we find this:

Doctors can be awful, and mistakes can be murderous, but the philosophy driving evidence-based medicine is not.
Let’s not worry about the odd cast of this sentence and assume he means: medicine is sometimes bad, EBM philosophy isn't.

In the same chapter he tells us about 13 per cent of all treatments have good evidence, and a further 21 percent are likely to be beneficial. A bit low, so he tries again. Ah, but if we look at how much medical activity is evidence-based that rises to 50-80 percent. Depending on how you interpret this and the method by which these figures were derived, that means a large chunk of medical practice has no evidence underpinning it.

In response to Archie Cochrane's call for up-to-date, systematic reviews of all relevant randomized controlled trials of healthcare, the Cochrane Collaboration was founded in 1993--perhaps the real birth date of EBM. But what happened before that?

OK, you say, we are where we are. So let’s not bother with what happened before. We are now flowing into an enlightened era of more scientific medical practice. Or are we?

We really do need to understand why the scientific approach seems to have been marginalised in medicine, because Sue Dopson’s Knowledge to Action? Evidence-Based Healthcare in Context suggests the flow to an enlightened era is turbulent. Interdisciplinary tensions, over assertive practitioners and the subjective conversion of evidence into practice make for erratic progress, it seems.

No matter how strong the philosophy of EBM may be it's in the integration into practice where the real patient benefits of it lie. Rather than trashing questionable reasoning in other practices, maybe Dr. Goldacre should redirect his laser logic onto that challenge. After all, conventional medicine is where most of us seek health care and where a substantial chunk of our taxes is spent.

October 01, 2008

Future Imperfect

Is a man in fluorescent gear riding a mountain bike a suitable metaphor for innovation, information and technology? The Health Service Journal Intelligence supplement* seems to think so.

The HSJ's coverage of such matters is usually low key. This probably reflects the interests of its readers, which is a shame. Mind they did publish one of my articles on healthcare IT which now seems 15 years ahead of its time (!)

The supplement considers Imperial College London's construction of a virtual model of a future NHS in Second Life. I visited the site a couple of years ago to look at a construct of Polyclinics, which was eerily empty at the time. This future world seems locked into current models of care with a general marginalisation of the role of ICT. We need to realise that demographic and epidemiological trends mean that is not sustainable.

The HSJ also considers emergency services, their adequacy and their future--hence the mountain biker. They say they are not as fully integrated into the system as they could be. And this touches a common theme througout the supplement: the benefits of sharing of information and of the integration of ICT into practice--whether by COIN or by joining insular GP systems. That is the future of healthcare.

*18 September 2008