Friday, 28 September 2012

What is truth, what is folly, and what is deceit?

At the weekend, I read with dismay Ben Goldacre's excellent article on the gaming of research results by the pharmaceutical companies ( I have known for a while that the desire to help patients stood in conflict with the financial bottom line, and I even knew that on occasions, drug companies suppressed results that they did not like, or failed to report on negative trials.

I cut my medical teeth at the time when we started using selective COX2 inhibitors for pain, only to find out that the efficacy data had only been published up to 6 months, as the data up to 12 months showed excess mortality. These drugs have now all but fallen out of use, which is right on the one hand (their incorporation into routine practice was based on flawed data) but a shame on the other hand - there were patients, particularly with rheumatalogical diseases who now have no access to medications that they actually found useful.

Ben Goldacre reminded me of this experience. But his effect on me went much further: he made me question how many times I have prescribed patients medications which I thought would be of use to patients, because the published papers showed benefit. What, however, I have learned is that for many of the medications I use, for every positive trial, there may well be a number of trials that showed no benefit.

Have I therefore been guilty of quackery? By today's standards, my decisions have all been justified, but in the future, when I look back at the actions I used to take, or the medicines I used to use, what will I think? I suspect there will be a number of medications that I use now that I will view with either embarassment or mirth.

I began with mirth when I was reading a beautifully written article in the New England Journal the other day, looking back at 200 years of therapies described and debated in the journals pages.

Blood letting, the therapeutic use of tabacco and trying to shock the body back into health are approaches to healing that we rarely sign up for today. But they made sense in the context of the medical knowledge of the time. In just the same way that the treatment choices we use today usually make sense in terms of our medical knowledge. Usually, but not always: I don't understand the use of ritalin in ADHD, I don't always understand the healthcare reflex to use anti-pyrexials to suppress fever, which has a biological purpose.

I guess we are quite good at persuading our actions to fit our understanding, rather than vice versa. I imagine we are more persuaded by the times our choices work than when they don't - treatment failure can be understood in other terms: they were too sick, too frail or presented too late.

The rise of empiricism in medicine has not wholly dispelled by the influence of personal experience on medical practice - and perhaps it shouldn't. But there are risks: for example, we know that doctors put too few people on anticoagulants, because of their experiences of dealing with the complications, even though the evidence suggests that the benefits outweigh the risks.

But our own personal experience gives us information that no randomised controlled-trial ever could - namely what it is like to be the patient. With our senses, we can tell what the patient going through, both from the illness and from the treatment. This is crucial - the quality of experience is central to how we practice.

But perhaps our own experience also gives us useful data on how well treatments work. After all, if Ben Goldacre is right, we shouldn't place all of our faith in the numbers we read in the journals. Sometimes, they just can't be trusted.

I don't want to be a cynical practitioner, but perhaps I need to be. Perhaps it's true that we can never truly know, and perhaps it is useful to remind oneself that medical practice is about the person in front of you, and not just the empirical evidence about what works and what doesn't.

I can live with the idea that in the future we will have a better understanding of disease than we do now, but what is difficult to handle, is that for some drugs, the knowledge that they don't work that well has always been known. Failure to share this kind of knowledge amounts to corporate selfishness. In these situations, it is greed and avarice that triumph over kindness and altruism, and that just seems so unnecessary.

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