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First, do no harm

21/10/2010

My dad – a GP – used to show me how he checked the methodology of research papers in the BMJ and then waited a while before prescribing the latest drugs for his patients. He kept a packet of a once-fashionable anti-emetic on his surgery windowsill, just to remind him not to rush into prescribing. It was for the morning-sickness wonder-drug Thalidomide.

The example of thalidomide is a stark reminder for those of us who work in research that we always need to test our findings and make sure that they are both internally but also ecologically valid – in other words, they must be both correct and meaningful in the real world context.

As researchers, we too need to check that we follow that first medical imperative: that you should do no harm. It applies to the researcher as least as much as to the clinician and must inform how we negotiate the interface between progress and care.

However, these days, for pharmacological interventions, there are pretty ferocious systems of checking and control established by national and governmental bodies to ensure that future potential cases like thalidomide do not occur. And rightly so: innovations that don’t work could have frankly disastrous results.

But, in this age of evidence based practice, how do professionals make use of research? And, as teachers, doctors and lawyers are notoriously conservative in their practice, so how do we as researchers help our colleagues to incorporate our findings into their work?

The first of these questions is discussed in an excellent paper by Raymond Ostelo and his colleagues from the Vrieje Universiteit in Amsterdam. It looks at how evidence based medicine tries to ensure that practitioners relied more on current knowledge rather than habitual or herd behaviour.

Resistance to this process may arise from an apparent lack of real-world relevance. The practice envisaged in a research study could appear to be very different from the setting, circumstances and resources available in the daily work of the practitioner.

One way to overcome this barrier has always been to get our papers published and reviewed in the appropriate journals, but it is no longer enough. These days, using social media allows us to explain the how and the why of our work’s importance more broadly than was ever previously possible.

Research findings are often made flesh through the promulgation of codes of practice or guidelines, but little is known about the best way to ensure implementation of such guidance.

Whether in the health sciences or in other areas of public service, the researcher almost always has an uphill struggle getting their results to have an impact upon professionals day-to-day practice.

An understanding of the realities of frontline practice and the necessary conservatism of professionals in the field will be needed, as will patient and innovative strategies for achieving change, if a positive transformation is to occur.

Ostelo, R., Croft, P., van der Weijden, T., & van Tulder, M. (2010). Challenges in using evidence to inform your clinical practice in low back pain Best Practice & Research in Clinical Rheumatology, 24 (2), 281-289

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From → Health, Research

4 Comments
  1. One has to understand some statistics: A “successful” drug helps roughly fifteen percent of patients in the preliminary studies. But it is marketed as the new breakthrough drug.

    We have to ask more often: What with the eighty-five percent of patients in whom the drug did not work? Medicine, as an endeavor, is absolutely not interested in those eighty-five percent. But those are the patients we could learn from.

    Alexa Fleckenstein M.D., physician, author.

    • Absolutely. I was looking at some stats just this afternoon and thinking – what about the 63% with whom this did not work?

  2. It’s system-inherent: Medical careers are made by finding a drug or a procedure – not by figuring out why something doesn’t work.

    Alexa Fleckenstein M.D., physician, author.

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