“Where is the wisdom we have lost in knowledge and the knowledge we lost in information?” Richard Smith.
There are new trends being followed in medicine, and new winds are blowing in this rather progressive field! The focus of this new ‘trend’ is, ‘what is the evidence?” You cannot get away by saying anything which cannot be supported by ‘evidence’. We need evidence to make a diagnosis and we need evidence to request investigations as to what are the chances of clinching the diagnosis by employing a certain investigation. To use a certain group of drugs we need evidence of its benefit and safety record. There are some very interesting stories about drugs. Many drugs which were though to be good for one indication turned out to be a remedy for another ailment. A drug called Captopril in the beginning was suppose to cause leakage of proteins from kidneys and we used to give albustix to our patients to check this. Now, it is being used for the treatment of the same leakage of proteins. A drug was introduced to treat high blood pressure but it was found that it had more effect on growth of hairs and now it is being used for baldness in the form of creams. Aspirin till very recently was used only as a pain killer, now it is being used for a host of new indications which were never through of before. It is become a ‘darling’ drug of doctors specially cardiologists, neurologists and all interested in blood vessels.
Where do we get this evidence from? We conduct trials, which means we give the drug to half of the defined population and the other half gets tablets similar in shape but without any active material. Or similarly we apply a certain diagnostic test to half of randomly selected and the other half serves as ‘control’ population. Statistical tests are applied to find out any ‘objective significance’. Trials are being conducted everywhere and the purpose is to answer a question. Most of these trials are placebo controlled and double blind which means to study the effect of drugs and compare with placebo and both patients and doctors do not know about the placebo, so that we can study the real effect of the drug per-se. Many trials are sometimes put together to answer a specific question and this is called meta analysis.
The reason ‘trials’ were invented land are being practiced so fervently, is that in the world of medicine two plus two is not always equal to four. Some drugs which appear very good in laboratory and animal experiments, produce disastrous results when tried in a large number of human beings. In the current scenario, whenever a new medicine or a new diagnostic technique is introduced, it is evaluated objectively and evidence is collected before it can be marketed and accepted for human use. A new drug has to be tested in head to head comparison with established therapy to prove its efficacy and establish its safety.
Evidence based medicine has been defined as, ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” But perhaps it can be more accurately defined as, “the enhancement of clinician’s traditional skills in diagnosis, prevention and related areas through the systemic framing of the relevant and answerable questions and the use of mathematical estimates of probability and risk.”
Most doctors have so far been making decisions on what we learnt from text books, on the basis of anecdotes – personal or those experienced by colleagues and seniors, press cuttings, expert opinions (known as eminence based medicine) and guided by cost minimization. But the correct way is to formulate ‘an answerable question’ from the available information. This may be about symptoms diagnosis correlation, diagnostic signs, diagnosis per-se, prognosis of illness, cost effectiveness of a procedure or treatment and other issues. Having formed a question best evidence is sought from clinical examination, laboratory workup and current literature consisting of published trials and meta analysis. The data is critically evaluated for its validity and usefulness in terms of clinical applicability. Then an opinion is formed in the light of this evidence. Next two steps are perhaps more important and essential. This evidence has to be incorporated in the clinical practice and then the performance has to be evaluated at regular intervals.
The critics among doctors who believe in traditional medicine are against it on the following grounds: “Evidence based medicine seems to replace original findings with subjectively selected, arbitrarily summarized, laundered and biased conclusions of indeterminate validity or completeness. It has been carried out by people of unknown ability, experience, and skills using methods whose opacity prevents assessment of the original data.”
Medical practitioners belonging to any walk of health science realize that many a times we have faltered on assuming things on their face value. Two plus two is not always four in the world of medicine, it can swing in any direction by any multiple. Estimates from early eighties suggested that only around 10-20% of medical interventions including drug therapies, surgical operations and X-rays and blood tests were based on sound scientific evidence.
Howe can doctors incorporate evidence based medicine in our clinics and hospitals so that our patients can benefit from it? There is no doubt that we should be all practicing evidence based medicine in our personal capacity and as health managers at the level of a unit, hospital or provincial level. How do we enforce evidence based medicine in our clinical practice? First of all identify and prioritize clinical, psychological and social problems. Perform a complete and competent clinical examination to establish a diagnosis. Consider additional problems and risk factors needing attention. Where ever necessary seek evidence from systematic reviews, guidelines, clinical trials, and other sources. Assess the evidence on account of completeness, quality and strength. More importantly ask yourself if valid and relevant evidence is being applied and is it both scientifically justified and intuitively sensible? Present the pros and cons of different options to the patient in easy to understand fashion and help to formulate a final recommendation. Most importantly arrange for review, recall, referral and further case wherever required.
_____________________________________________
Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah
There are new trends being followed in medicine, and new winds are blowing in this rather progressive field! The focus of this new ‘trend’ is, ‘what is the evidence?” You cannot get away by saying anything which cannot be supported by ‘evidence’. We need evidence to make a diagnosis and we need evidence to request investigations as to what are the chances of clinching the diagnosis by employing a certain investigation. To use a certain group of drugs we need evidence of its benefit and safety record. There are some very interesting stories about drugs. Many drugs which were though to be good for one indication turned out to be a remedy for another ailment. A drug called Captopril in the beginning was suppose to cause leakage of proteins from kidneys and we used to give albustix to our patients to check this. Now, it is being used for the treatment of the same leakage of proteins. A drug was introduced to treat high blood pressure but it was found that it had more effect on growth of hairs and now it is being used for baldness in the form of creams. Aspirin till very recently was used only as a pain killer, now it is being used for a host of new indications which were never through of before. It is become a ‘darling’ drug of doctors specially cardiologists, neurologists and all interested in blood vessels.
Where do we get this evidence from? We conduct trials, which means we give the drug to half of the defined population and the other half gets tablets similar in shape but without any active material. Or similarly we apply a certain diagnostic test to half of randomly selected and the other half serves as ‘control’ population. Statistical tests are applied to find out any ‘objective significance’. Trials are being conducted everywhere and the purpose is to answer a question. Most of these trials are placebo controlled and double blind which means to study the effect of drugs and compare with placebo and both patients and doctors do not know about the placebo, so that we can study the real effect of the drug per-se. Many trials are sometimes put together to answer a specific question and this is called meta analysis.
The reason ‘trials’ were invented land are being practiced so fervently, is that in the world of medicine two plus two is not always equal to four. Some drugs which appear very good in laboratory and animal experiments, produce disastrous results when tried in a large number of human beings. In the current scenario, whenever a new medicine or a new diagnostic technique is introduced, it is evaluated objectively and evidence is collected before it can be marketed and accepted for human use. A new drug has to be tested in head to head comparison with established therapy to prove its efficacy and establish its safety.
Evidence based medicine has been defined as, ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” But perhaps it can be more accurately defined as, “the enhancement of clinician’s traditional skills in diagnosis, prevention and related areas through the systemic framing of the relevant and answerable questions and the use of mathematical estimates of probability and risk.”
Most doctors have so far been making decisions on what we learnt from text books, on the basis of anecdotes – personal or those experienced by colleagues and seniors, press cuttings, expert opinions (known as eminence based medicine) and guided by cost minimization. But the correct way is to formulate ‘an answerable question’ from the available information. This may be about symptoms diagnosis correlation, diagnostic signs, diagnosis per-se, prognosis of illness, cost effectiveness of a procedure or treatment and other issues. Having formed a question best evidence is sought from clinical examination, laboratory workup and current literature consisting of published trials and meta analysis. The data is critically evaluated for its validity and usefulness in terms of clinical applicability. Then an opinion is formed in the light of this evidence. Next two steps are perhaps more important and essential. This evidence has to be incorporated in the clinical practice and then the performance has to be evaluated at regular intervals.
The critics among doctors who believe in traditional medicine are against it on the following grounds: “Evidence based medicine seems to replace original findings with subjectively selected, arbitrarily summarized, laundered and biased conclusions of indeterminate validity or completeness. It has been carried out by people of unknown ability, experience, and skills using methods whose opacity prevents assessment of the original data.”
Medical practitioners belonging to any walk of health science realize that many a times we have faltered on assuming things on their face value. Two plus two is not always four in the world of medicine, it can swing in any direction by any multiple. Estimates from early eighties suggested that only around 10-20% of medical interventions including drug therapies, surgical operations and X-rays and blood tests were based on sound scientific evidence.
Howe can doctors incorporate evidence based medicine in our clinics and hospitals so that our patients can benefit from it? There is no doubt that we should be all practicing evidence based medicine in our personal capacity and as health managers at the level of a unit, hospital or provincial level. How do we enforce evidence based medicine in our clinical practice? First of all identify and prioritize clinical, psychological and social problems. Perform a complete and competent clinical examination to establish a diagnosis. Consider additional problems and risk factors needing attention. Where ever necessary seek evidence from systematic reviews, guidelines, clinical trials, and other sources. Assess the evidence on account of completeness, quality and strength. More importantly ask yourself if valid and relevant evidence is being applied and is it both scientifically justified and intuitively sensible? Present the pros and cons of different options to the patient in easy to understand fashion and help to formulate a final recommendation. Most importantly arrange for review, recall, referral and further case wherever required.
_____________________________________________
Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah
0 comments on "ARTICLE XIV - Evidence Based Medicine – What is it?"
Subscribe in a Reader
Post a Comment