Heroes Not Zombies

In the field of medicine there’s an interesting split between experience-based approaches and theory-based ones. I suppose it’s always been like that but in recent years Professor Sackett and colleagues’ approach to research has created something called “Evidence Based Medicine” (EBM) which, in it’s initial conception seems a very sensible idea, but which has, I feel, been distorted somewhat in recent years. Some people have taken Sackett’s method and applied the results to produce one-size-fits-all interventions and this was never the good Professor’s original plan. (He is in fact quite specific about the importance of the individual patient’s values and preferences in making treatment decisions). The one-size-fits-all approach is used to exert financial controls on health care and is promulgated by the “trust me, I’m an expert” brigade.

When it comes down to an individual patient, only this person can tell us about their pain or their other troublesome symptoms. Only this person can tell us what impact a treatment has made on their symptoms. In fact, we have all had the experience that a medicine which somebody else found helpful turns out to be hopeless for us (you can apply this to every form of medicine).

This was famously alluded to by Dr Roses of Glaxo who said –

“The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people,” Dr Roses said. “I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.”

My daily work is as a practising doctor. My priority therefore is to try my best to help each individual patient I meet. Yes, if there is a theoretical benefit available from a particular drug, then I should consider it, but, it wouldn’t help the patient if I didn’t bow to their experience. There’s no point banging on with the same treatment which a patient is telling me is not working for them. I really dislike the arrogance of those who claim to know what is best for each and every patient on the basis of “research” or “evidence”. It turns out that many patients don’t actually get the benefits in experience which the “evidence” theoretically offers.

Let me be clear – research is a good idea. It helps us to see what potentials treatments hold. What it doesn’t do is tell us what this individual patient will experience as a result of this individual treatment. We need to retain our humility as practitioners and never assume we know for certain what a patient needs in the way of treatment.