Do We Have The Evidence?

The talk of the town (in Anytown, USA) is "Evidence-Based Medicine". If you're in the health professions, I am sure you've become familiar with the phrase. The same holds for those in health insurance - and clinical research. "The evidence" is driving everything these days.

For the record - I am a true believer in the power of good clinical research. I do think that as clinicians we need to provide care based on true evidence-based medicine. We must hold ourselves to high standards of practice, and we must continue to challenge our thought processes and clinical reasoning skills - as uncomfortable a process as this may be. It involves reflection on our practice patterns and perhaps even challenging our belief systems - about our role in patient care or the methods we advocate.

Having said that (and believing it deeply), I also think that much of the literature that poses as "research" is in fact self-serving and undermines the true goal of clinical trials. Money can certainly create a bias, and what happens if you show that what you believe in isn't beneficial? No worry, you'll be able to find some statistical measure that will confirm the benefit of your treatment (albeit perhaps no better than the placebo effect), or you simply write your conclusion to indicate that "more research is necessary".

Clinical research (and in the bigger picture, academia) is now more about what journal you've been published in, or how long you've been tenured. In a clinical profession, oftentimes this also correlates directly with the time away from the treatment of patients in the clinic.

So here's an interesting conundrum. Those who are doing the research - well, they may be so far removed from the clinic that they may not know what relevant questions to ask. Or ... perhaps they ask questions that are truly irrelevant to the average injured person living on planet earth.

It's all about publication value. Credibility. So where are our students in this mix? Worse yet, where are our patients in this mix - those whose quality of care would seemingly depend upon it? 

Fortunately, the literature related to human cellular physiology is well-documented over the past 3 decades and forms a solid platform upon which to base sound clinical reasoning. Unfortunately, when people refer to "evidence-based medicine" they overlook "cellular physiology" in their eagerness to find the all-knowing, all-encompassing RCT (randomized clinical trial).

As I have moved forward in my clinical practice, I have come to find that cellular physiology doesn't let us down - ever.

The scientific method involves establishing a relevant hypothesis from clinical observations - then testing that hypothesis. McKenzie made observations on thousands of patients in the clinic - then tested his hypotheses in a similar fashion. He knew how to observe - as all great scientists do.  Of course, if you have the astute observational skills of a McKenzie, you will know which questions to ask - and how to ask them. It involves being a clinician first and foremost - not a researcher.

Perhaps this is the premise that "clinical research" should be formed upon - not on highly-exalted publication, tenure, and self-glorification and guru-ization. Professional education should involve the development of better clinicians with improved clinical reasoning skills - not better researchers with better statistical software.

And within all of this - let us remind ourselves - that it's all about the student ... and the primary student we have is the patient.