Letter

On the trial trail

Dear healthmatters—I was very pleased to see your editorial (The appliance of science, issue 23) but I felt that your reservations about evidence-based medicine were unduly pessimistic.

The first point you made was that evidence-based medicine was not appropriate for complex problems but this is not the case, as a recent randomised controlled trial in the management of chronic fatigue syndrome demonstrates.¹

Furthermore, one technique developed by the practitioners of evidence-based medicine has been the ‘N-of-1’ randomised trial in which, with the patient’s agreement, both doctor and patient participate in a trial which allows them to identify whether or not a particular intervention has a beneficial effect on a complex and multifaceted health problem, for both doctor and patient may find it hard to determine the effect of a single intervention.

Your second reservation was that evidence-based medicine appeared to negate value judgements but nothing could be further from the truth. Evidence-based decision making is evidence-based. The patient’s values always have to be taken into account. This is of great importance to patients, for how can a patient make a choice on an issue of value to them unless the information they are given is evidence-based and not simply opinion unsubstantiated by research?

Your third comment was that evidence-based medicine relied on randomised controlled trials. Evidence-based medicine argues that the clinician and the patient should use the best evidence available but if there are no trials of sufficient quality then other sources of evidence have to be used, but both clinician and patient should be aware of the strength of the evidence and its reliability. The point that you make about the need to take into account the individual’s own particular condition is well made but evidence-based medicine emphasises the need not only to find and appraise the best evidence possible but also to use techniques to apply that evidence to take into account the risks and potential benefit for the individual patient with whom they are discussing treatment options.

We see evidence-based patient choice as of equal importance to evidence-based clinical practice. Patients need to be given information that will allow them to distinguish between personal opinions and recommendations for action based on high quality research.