Neil,

Thanks for your comments. I agree that there's always going to be some
degree of conflict between ensuring the rigour of an RCT and its broader
clinical relevance. Research is all about manipulating a small number of
variables in lots of people, whereas clinical practice is all about
manipulating lots of variables in individuals. The individual prescription
approach you are suggesting is certainly a good idea, but practically, I
can't see it working.

You said:

>>If a trial was developed where the subjects where split
into MANY groups based on the criteria an experienced clinician came up with
that would influence him/her to give one or another course of (often a
succession of different) treatments, in other words make the trial more like
the way we do things in clinical practice, then perhaps a paper could be
published that would show how we DO successfully treat them. <<

How would you select the clinician?
Do you think that if you picked ten experienced clinicians they would all
have the same approach?
I would be very surprised if you could get ten experienced clinicians to
completely agree on any treatment approach, particularly something as
variable as wart treatment.

>>At the moment I
get lots of long term VP's that are now (I believe) more difficult to treat
because the patient has been wasting their time with ineffective treatments
either from the GP or OTC home treatments, or have been advised by their GP
not to bother treating it as it will go away on it's own, i.e. they don't
know how to treat it.

Just to play devil's advocate here...

How do you know that GPs in your area aren't seeing as many of your
unsuccessfully treated patients as you are of theirs? And how do you know
whether some of these warts would have gone away on their own?  This is one
of the limitations of the knowledge gained through clinical practice - its
unavoidably biased. That's not to say that its wrong, but you can't be
totally sure that its right. For example, a lot of podiatrists would say
that hallux valgus surgery often doesn't work, as they've seen the results
of failed treatment in their clinics. At the same time, however, a lot of
orthopaedic surgeons would say orthoses don't work, as they're seeing a lot
of failed orthotic therapy cases.

Don't get me wrong - I'm no evidence-based medicine zealot, and there's
definitely some inherent problems in conducting systematic reviews and
applying research evidence to clinical practice. However, I strongly believe
that evidence obtained from well-performed trials is more convincing than
anecdotal evidence gained from clinical experience. I also think that some
clinicians have a somewhat skewed understanding of what evidence-based
medicine actually is. For a very balanced view of this, go to:

http://bmj.com/cgi/content/full/324/7350/1350

The basic argument here is that "evidence based medicine was developed to
encourage practitioners and patients to pay due respect - no more, no less -
to current best evidence in making decisions". I don't think anyone could
argue with that.

Kind regards,

Hylton

Hylton B. Menz
Research Fellow
Prince of Wales Medical Research Institute
High St, Randwick NSW 2031
ph. 61 2 93827965
fax. 61 2 93822722
www.powmri.unsw.edu.au/FBRG/FBRGhome.htm

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