Treatment based on evidence-based medicine


  • Wellness
  • Thursday, 14 May 2020

Is your first reaction when you are ill to look your symptoms up on Google? Do note that the search results you get are based on popularity and advertisements, rather than medical expertise. — AFP

Picture the scene: It’s Monday morning in an already crowded clinic and I’m seeing my first patient.

“Doctor, can you please help me? My husband has just come out of HKL (Hospital Kuala Lumpur). Heart failure, they said.

“I don’t know what is best for him. I have been told so many different things from relatives, friends etc.

“And I’ve been on Google and Wikipedia – everything lah. Now I’m more confused than ever. What to do ah?”

Phew! How do you respond to that?

This is exactly the scenario where reliable, accurate, easily-accessed information based on scientific evidence will put this woman’s mind at rest, and offer safe and effective treatment for her husband.

Information to solve clinical questions like this is best obtained from trusted sources.

Don’t just search on Google for it! Google ranks information for its searches by the number of times people click on the link and advertising.

That’s fine if you want to find out who was the captain of Arsenal in 1956 – you can just take the first answer and be fairly sure it is the right one. Not for medical evidence though.

A raw Google search has no filters to separate out the information: it’s like trying to take a sip of water from a broken fire hydrant.

Using resources like the Cochrane Library, Pubmed, Dynamed, Up To Date etc will provide you with information already evaluated by experts as accurate and relevant to your clinical question.

Reviewed By Experts

And how do these resources ensure that their information is accurate?

Firstly, they ensure that a clear clinical question is asked.

They break down the question into its component parts so that it is crystal clear what is being asked.

Putting the components together, the doctor can ask this question: “In middle-aged men with heart failure (just like this woman’s husband), does ramipril (one type of drug), when compared to furosemide (a water tablet), lead to a reduced need for admission to hospital?”

The answer to this question will help both doctor and patient reach a decision about what medication is best for the patient.

The next challenge is: where do we search?

Clearly not Google as its search results are not peer-reviewed.

The results are raw information with no scrutiny by medical experts.

All reputable medical journals use a peer-review process before articles can be published: the research paper is sent out to doctors around the world for their views.

If there are serious flaws, then the researchers have to address them.

If they do not do so or do so unsatisfactorily, the paper will not be published.

Remember the paper linking the MMR (measles, mumps and rubella) vaccine and autism?

That should never have been published as the research method was flawed. It was later retracted by the journal that originally published it.

We use the sources mentioned previously – the Cochrane Library, Pubmed etc – for good reason.

They have already pre-evaluated thousands of articles rigorously to ensure that they are accurate.

Now we are drinking from a tap, not a fire hydrant, and the water is of much better quality.

For The Public

For the general public, things are more challenging. You are bombarded with claims and boasts of the benefits to your health of so many products. It can be bewildering.

You will read advertisers using phrases like “clinically proven” or “studies have shown”, so how do you decide if it’s true or if it’s “fake news”?

Fortunately, many of the reliable information sources quoted above also provide services for the general public, e.g. the Evidently Cochrane website from the Cochrane Collaboration.

These summaries of the best available evidence are written in plain English that is easy to understand.

The Cochrane Collaboration is now a global group with branches in most countries, including Malaysia (based in Penang).

The PICO question above helped this woman’s husband very much: he chose to take ramipril because the research he reviewed with the help of his doctor showed that taking ramipril would reduce his chances of being readmitted to the hospital.

Staying out of hospital was very important to him.

The other drug, furosemide, like ramipril, also helps with breathlessness, but has no impact on hospital admissions.

Safe And Effective

Critics of evidence-based medicine say that it just ticks the boxes and is not “real” medicine.

If providing a patient with access to the best available medical evidence quickly and in an easily-understandable way for them to make informed decisions about their health is not real medicine, then I wonder what is?

This approach is respectful of patients’ concerns and gives patients a voice, something that is sorely lacking in many countries today.

It improves patient safety through the use of proven interventions, such as drugs or surgical procedures, whose potential harms are outweighed by their benefits.

It combines the patient’s concerns with the best available evidence and the doctor’s own expertise, all designed to deliver safe, high-quality patient care together.

Evidence-based medicine is both safe and effective, fostering true sharing between patient and doctor for the best quality care.

You, the public, need advice you can trust.

Right now, during this Covid-19 pandemic, you are receiving conflicting information, e.g. about hydroxychloroquine and disinfectant in the treatment of Covid-19.

US President Donald Trump has advocated for both as cures.

But the evidence from clinical trials for hydroxychloroquine is conclusive: it is both ineffective and harmful.

As for ingesting or injecting disinfectants: would any rational person promote this?

The manufacturers of disinfectant products have had to rush to release statements advising customers to never do this.

In Malaysia, there are many community-based doctors who are members of the Academy of Family Physicians of Malaysia working in Klinik Kesihatan and private clinics.

They will act in your interests to promote an evidence-based approach to your care. Trust your doctors!

Dr Isriyanti Mohd Rafae is a senior lecturer and Dr Anthony Cummins is the Foundation Professor at the Department of Family Medicine in RCSI-Perdana University. This article is courtesy of Perdana University. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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