Dear Vicki
We have to remember that the rct is ONLY 50 years old. Opinion ruled
prior to the 1950's. Doctors have about 2000 years of a belief in the
anecdote & counting is not an intuitive activity among doctors.
The problem lies in the division in pre-clinical and clinical education in
students: they do "science" in the first half and the "real" medicine in
the second. They chat among themselves about how the preclinical
epidemiology etc was "dry as dust" or "boring". They liven up with the
clinical encounter. If there were no such divison, then perhaps there
would be fewer problems.
The problem is one of a belief in counting. I live in a culture that does
not value counting (being a mathematician is nowhere near as glamourous as
being a doctor or an all-black).
The solution will come when more and more patients demand a quantified
answer. when they ask: "how many survive"? or "What is the risk"? Or "how
useful is this test"? then the quality of the doctor is determined by HOW
the answer is given. The future doctor will put a human face to numbers. I
have no idea how or when such a future will occur
In new zealand we (doctors) are going through another painful episode of
exposure to our lack of a feeling for numbers. A pathologist missed many
cervical smear cancers over time. There seemed to be no checks and
balances over his clinical life's work. The old arguments about "clinical
disagreement" and "levels of evidence" come to play in the glaring light of
public exposure. Many women now suffer because of what happened to their
smear tests. The women suffer as an apparent consequence of the lack of
belief in counting by the pathologist and other doctors. It seems the
pathologist was not counting how well he did, or how well he compared with
peers. (He was his own gold standard and would have done well in Galen's
time).
The virtue of clinical epidemiology is that it tries to provide a means to
clarify important issues so that doctors and patients can talk rationally
about diagnosis, tests, treatment, or prognosis. Clinical epidemiology has
no place in a practice of medicine that does not believe in rationality. I
do muse about a clinical epidemiological study of irrational behaviour - if
it is SO WRONG to be irrational why did humans evolve to have so much of
it?
cheers
marjan
Dr Marjan Kljakovic
Senior Lecturer in General Practice
Wellington School of Medicine
University of Otago
PO Box 7343
Wellington South
New Zealand
Tel 64-4-385 5995
Fax 64-4-385 5539
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