Description

Evidence-based medicine is an invaluable way of judging how well a mathematical model has been implemented in the design and analysis of a number of clinical research reports. Randomised control trials (RCTs) form its cornerstone and are hailed as its gold standard. Clinical research based on mathematical models confirms reproducibility of measurement of observations and tests the effectiveness of treatment modalities. However, evidence-based medicine is not infallible; indeed it may be misleading as in the case of the poorly conceived and designed Heart Estrogen Progestin Replacement (HERS) Study. Such RCTs on which the evidence has been based have been re-labelled by some “evidence-biased”. Confidence in mathematical models is repeatedly eroded in practice largely because of the variability of the biological phenomena. In addition, many clinical conditions, such as menorrhagia, are so poorly classified that they do not lend themselves to any model of scientific analysis. Furthermore, randomised clinical trials incorporate highly selected patients, from highly selected centres, and are conducted by highly selected doctors, and consequently fail to apply to the more common grey cases. Indeed, RCTs may successfully answer questions related to acute clinical episodes. However, for chronic conditions where a number of biological, environmental and social factors, such as the long-term effects of oral contraceptives and HRT, interact with the outcome, RCTs tend to degenerate into purely observational studies.

The advent of clinical guidelines, largely based on RCTs and even worse on meta-analyses, poses serious questions about the applicability of these guidelines to everyday practice. Where these guidelines become the legal yardstick against which clinical performance is judged, the practising physician is forced to find a diagnostic match for the clinical situation at hand, in order to fulfil the management steps embodied in these guidelines, as the experience with managed care in the USA suggests. Non-compliance with prescribed guidelines entails the risk of disciplinary action, and the recently mooted “clinical governance” will haunt a future career. The best application of clinical knowledge is to apply the “evidence-based” published literature to the individual patient, in the form of “decision analysis” (discussed in this issue). This goal is nevertheless not easy to achieve in this climate of resource deprivation within the NHS.

The public concern regarding “sub-optimal” performance of medical practitioners, even though it happens very infrequently and indeed rarely, is justified. But some royal colleges gave a knee-jerk response to these concerns, reflecting the low morale among medics. This profession has been driven into a corner, where it has to absorb the barrage of media frenzy, including that of leading medical journals, and the bullying tactics of politicians. Knee-jerk responses usually result in poorly evaluated solutions. The royal colleges are made to act fast, in order “to be seen” to be doing something. The deployment of clinical guidelines, which in their proliferation end up with inevitable disagreement, will subsequently be policed through clinical governance.

Surgical specialities have been the main targets of media and public criticism, mainly because of their dramatic nature. Surgery of any type carries the risk of complications. One may ask therefore how many complications and of what nature should be observed before the whistle is blown? and by whom? Moreover, surgery conducted by the same surgeon with different supporting staff may suffer from delays and adverse events; the same applies to other specialities. The short duration of training of specialist registrars, and the pressure imposed on quantity production to reduce waiting lists pose the question how improved training can be achieved? Who pays for practical training courses? A sabbatical may be an answer but one must not underestimate the effect this leave of absence may have on the local hospital and even more so on the hosting centre. In a sabbatical of fixed duration, how many procedures should the visiting doctor perform under supervision before being declared safe to practise independently? And when returning to the base hospital, what allowance can be made for the inevitable learning curve? Who will pay for the lost income for the individual doctor and the disruption such a sabbatical may cause to family life, particularly to women doctors? These personal issues have been considered taboos in our profession and may never be mentioned, but they are simple facts of life given the dilapidating pay scale, which has failed to keep parity with equivalent professions.

The demands for robotic performance on the part of the medical profession and the abridged apprenticeship of future consultants are not in the best interest of the patient. Indeed, they only serve a political agenda desperately trying to sustain a health care system designed for a different generation and a different socio-economic era. Quality of life issues, particularly in the field of womens health care command a completely different investment strategy in order to deliver the quality of care the public deserves. The panacea suggested to resolve all these issues is “clinical guidelines” and “clinical governance”, in which politicians and the public have invested their hopes heavily. The “practice of medicine by proxy” will not answer the plea of the patients for individualised care expected from their doctor, unless the taxpayer accepts the unthinkable and pays more to separately fund a modern national health service.