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The 1998 Skeptic
of the Year, awarded by the Australian Skeptics Inc,
is Michael Archer, a palaeontologist and professor of biological
science at the University of New South Wales, who has recently been
appointed Director of the Australian Museum. His interests listed on
his Internet home page include "all aspects of zoology and
palaeontology that relate to the development of the Australian
biota, particularly mammals", and "pseudoscience such as creation
science".1 The award is presented to
Australians whose work contributes substantially to the promotion
of critical thinking.2 Perhaps there should be an
equivalent award given each year to the doctor who has best practised
lifelong sceptical medicine! Some confuse sceptical medicine with
the practice of a nihilistic, cynical clinical code. But Archer, in a
recent radio interview, made a clear distinction between scepticism
and cynicism: the former pursues evidence and is built on humility;
the latter reflects arrogance and seeks to destroy virtue. The
distinction could hardly be plainer.
The Health Advisory Committee of the National Health and Medical
Research Council and the Menzies Foundation recently convened a
workshop* to define the current state of the art of evidence-based
medicine, and potential implications of and barriers to an
evidence-based approach to healthcare in Australia. The aim was to
develop ways of incorporating an evidence-based approach into the
Australian healthcare system for the next millennium. Different
perspectives were explored, including those of healthcare
professionals, consumers, health policymakers, researchers,
lawyers and funding agencies.
David Pencheon, the UK National Health Service's Associate Director
of Research and Development, spoke of a recent encounter with new
medical students beginning clinical training in Cambridge after
intense preclinical education. He asked them questions about simple
clinical observations, and their mechanism and meaning. He recalled
that it took a long time before he had exhausted their knowledge and one
of them finally uttered that most important of all phrases for the
future practice of scientific medicine "I don't know!".
To admit to not knowing, or to being unsure until the evidence is
gathered or accessed, is surely the beginning of sceptical wisdom.
Without it, clinical practice guidelines, and ready access to
relevant databases or information about the appropriateness of
investigations and treatments, are useless -- because the mind of the
clinician is not sceptically engaged. Just as a palaeontologist
fails who ceases to look for evidence in fossil deposits, so a
clinician who forsakes evidence in favour of intuition or
half-remembered ideas runs a significant risk. Learning to say to
oneself, one's patients and one's colleagues "I don't know" is a vital
element of medical education.
Papers presented at the workshop examined how healthcare decisions
are made, how evidence is synthesised and disseminated and how
evidence-based treatment is implemented, and the impact of using an
evidence-based approach. Evidence-based medicine is a provocative
term, not least because it begs the question whose evidence? While
formal and standard definitions of evidence-based medicine show due
deference to patient values and evidence from clinical
experience,3 there remains a suspicion in
the minds of many that this is a new way for purveyors of randomised
controlled clinical trials to take over the world.4 This fear may be
as straightforward as a professional territorial concern or as
complex as the insight held by patients, members of the community and
behavioural and social scientists that there is more to the clinical
decision omelet than randomly cracking a few clinical trial eggs.
Thus, Ian McDonald (Director, Study of Clinical Practice, St
Vincent's Hospital, Melbourne) argued that clinical decisions, if
properly understood, have a base of scientific evidence familiar to
the biological scientist, but that we often fail to understand that
other forms of evidence, from studies in sociology, behavioural
science and anthropology, are helpful in achieving a full
understanding of medical care. His challenge, echoed by Hilda
Bastian (Chairperson, Consumers' Health Forum) and Sophie Hill (PhD
student, School of Public Health, La Trobe University), was to a new
form of scepticism, questioning the completeness of our definition
of evidence-based medicine if it does not include knowledge
generated from these other disciplines.
Likewise, Sydney University's George Rubin (Professor of Public
Health and Community Medicine) reminded participants of the
relevance of a scientific understanding of motivators of
behavioural change in other human settings (eg, business, which
refers regularly to the relevant literature and is based on due
scepticism) when contemplating how to encourage behavioural change
among clinicians. The Australian National University's Bob Douglas
(Director, National Centre for Epidemiology and Public Health)
proposed that all health facilities and administrative units employ
health information analysts, or "Cochrane-ologists", to assist
health professionals to make use of evidence and manage scepticism.
Multiple pressures operating on practitioners can lead them to
ignore what they know to be best practice in their clinical and public
health decision-making. These pressures include well-coordinated
commercial interests, time and financial constraints, and the
potential for litigation.
Workshop participants asked that the Health Advisory Committee
consider the following recommendations and develop an action plan to
support their implementation:
- To recognise that
systematic reviews underpin evidence-based healthcare.
Systematic reviews should be required for all future
healthcare-related research. They should be accepted as a
legitimate form of research and developed to include a wide range of
scientific evidence. Reviews should be eligible for research
funding, and recognised in research performance assessment and as
accreditation towards postgraduate training.
- To identify and overcome factors that hinder the generation,
transfer and implementation of research knowledge into clinical
practice. It is important to establish mechanisms and funding
for ongoing communication and structural collaboration among
groups involved in this area in Australia and overseas.
- To encourage the use of evidence-based approaches in areas
outside clinical practice. These include the development of
health and public health policy and practice and health-related
litigation.
If, as many believe, there needs to be a cultural shift to greater use of
evidence in making not only life-critical but also day-to-day
clinical practice and public health decisions, it will be important
for the evidence to be immediately accessible either in hard copy or
via computer to a range of potential users -- clinicians, consumers
and health service planners. There is no point in providing clinical
guidelines to clinicians about conditions or problems they will
never encounter, or presenting them in a way that they can not be used.
As Peter Joseph, immediate past president of the Royal Australian
College of General Practitioners, has said, "I want guidelines in the
form of charts that I can keep in an A4 folder on my shelf and pull down
immediately when I have a patient to whom they refer. Then I can locate
the patient in the decision matrix, explain to him or her where we are,
and walk through the decisions that we then have to make together"
(personal communication). The NHMRC's clinical practice
guidelines for the management of early breast cancer5 is a fine example
of guidelines prepared in a variety of formats to suit the needs of
different end-user groups.6,7
Evidence-based medicine can only operate in a
climate of healthy scepticism. Those who worry about their
colleagues' scepticism towards evidence-based medicine should
wait: if the doubters are genuinely sceptical, and if evidence-based
medicine works, it will not be long before they, too, have begun to make
the best use of it in an admittedly highly complex setting.
Stephen R Leeder
Professor, and Dean, Faculty of Medicine, University of Sydney, NSW
Chris A Silagy
Director, Australasian Cochrane Centre, and Professor of General
Practice
Department of Evidence-Based Care and General Practice
Flinders University School of Medicine, Adelaide, SA
George L Rubin
Professor of Public Health and Community Medicine, and
Director,
Effective Healthcare Australia, University of Sydney, NSW
- http://www.unsw.edu.au/bioscience/archer.htm
-
http://www.skeptics.com.au/
-
Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence based
medicine: what it is and what it isn't. BMJ 1996; 312: 71-72.
-
Lelorier J, Gregoire G, Benhaddad A, et al. Discrepancies between
meta-analyses and subsequent large randomised, controlled trials.
JAMA 1997; 337: 536-542.
-
National Health and Medical Research Council. Clinical practice
guidelines. The management of early breast cancer. Canberra:
NHMRC/AGPS, 1995.
-
National Health and Medical Research Council. Early breast
cancer. A consumer's guide. Canberra: NHMRC/AGPS, 1995.
-
National Health and Medical Research Council. All about early
breast cancer. Sydney: NHMRC National Breast Cancer Centre, 1996.
©MJA 1998
* Proceedings of the workshop are available on CD-ROM and via the Internet at <www.vicnet.net.au/~menzies> and <www.health.gov.au/nhmrc> |
