Half full or half empty VATS?
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《英国医生杂志》
1 Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU
Correspondence to: P McCulloch petermcculloch@doctors.org.uk
These paired studies on video assisted thoracic surgery (VATS) highlight a challenging question for proponents of evidence based medicine.1 2 After 10 years and, in this case, 12 randomised trials, why is practice so variable in specialties where the evidence seems clear? Is evidence based medicine, in fact, ineffective in changing clinical practice?
Disillusion is the child of overoptimism, and we should reflect that many influences for good remain of value despite less than universal adoption. Neither the United Nations nor the European Union has fulfilled all the ideals of their founders, but only their fanatical opponents would deny them some major achievements. Unsystematic review of recent medical progress makes a reasonably convincing case that evidence based medicine also has things to be proud of. Compared with 10 years ago, policy decisions in national health care in Europe and the United States are now informed much less by expert consensus conferences and much more by systematic reviews of the evidence. Medical journals publish more randomised trials, systematic reviews, and meta-analyses than they used to and require a higher degree of rigour in conducting and reporting studies, so the average quality of published medical research has gone up. Clinicians generally are now much more aware of principles of evidence based medicine and demonstrate this through typical guilt responses when they are forced to reveal their non-evidence based practices publicly. Guilt is said to be the first step on the road to redemption, so clinical practice too may be changing for the better.
Another important reflection is that evidence never was and never will be the whole story in medical decision making. Local resources, costs, and, particularly in the case of surgical techniques such as VATS, training needs are among the many practical and organisational barriers to changing established treatments. The systematic review reports that experience with VATS did not correlate with the proportion of eligible cases performed by VATS. This suggests that some units choose to use the technique selectively, but it might also mean that some surgeons never achieve comfort with it and abandon it after a trial period. An extensive psychological and sociological literature points to barriers to change erected by the minds of individuals and by the shared values and traditions of groups.3 4 Evidence is only one lever in the process of bringing about change, and it needs to be applied at the right point and in the right way in an organisation to be effective. This does not mean that we should give up on it, but that in our quest for quality improvements in health care we should also start to look much more seriously at how change is effectively achieved in organisations. G K Chesterton, a devout Catholic, once described Christianity as having: "not been tried and found wanting; it has been found difficult and left untried."5 While I would hope that the same fate does not ultimately befall evidence based medicine, the evidence so far does not convince me that it won't.
Competing interests: None declared.
References
Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials. BMJ 2004;329:
Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Variation in use of video assisted thoracic surgery in the United Kingdom. BMJ 2004;329:
Plous S. The psychology of judgement and decision making. New York: McGraw-Hill, 1993.
Timmermans S, Berg M. The gold standard: the challenge of evidence-based medicine and standardization in health care. Philadelphia: Temple University Press, 2003.
Chesterton, GK. What's wrong with the world. New York: Dodd, Mead, 1910.(Peter McCulloch, reader i)
Correspondence to: P McCulloch petermcculloch@doctors.org.uk
These paired studies on video assisted thoracic surgery (VATS) highlight a challenging question for proponents of evidence based medicine.1 2 After 10 years and, in this case, 12 randomised trials, why is practice so variable in specialties where the evidence seems clear? Is evidence based medicine, in fact, ineffective in changing clinical practice?
Disillusion is the child of overoptimism, and we should reflect that many influences for good remain of value despite less than universal adoption. Neither the United Nations nor the European Union has fulfilled all the ideals of their founders, but only their fanatical opponents would deny them some major achievements. Unsystematic review of recent medical progress makes a reasonably convincing case that evidence based medicine also has things to be proud of. Compared with 10 years ago, policy decisions in national health care in Europe and the United States are now informed much less by expert consensus conferences and much more by systematic reviews of the evidence. Medical journals publish more randomised trials, systematic reviews, and meta-analyses than they used to and require a higher degree of rigour in conducting and reporting studies, so the average quality of published medical research has gone up. Clinicians generally are now much more aware of principles of evidence based medicine and demonstrate this through typical guilt responses when they are forced to reveal their non-evidence based practices publicly. Guilt is said to be the first step on the road to redemption, so clinical practice too may be changing for the better.
Another important reflection is that evidence never was and never will be the whole story in medical decision making. Local resources, costs, and, particularly in the case of surgical techniques such as VATS, training needs are among the many practical and organisational barriers to changing established treatments. The systematic review reports that experience with VATS did not correlate with the proportion of eligible cases performed by VATS. This suggests that some units choose to use the technique selectively, but it might also mean that some surgeons never achieve comfort with it and abandon it after a trial period. An extensive psychological and sociological literature points to barriers to change erected by the minds of individuals and by the shared values and traditions of groups.3 4 Evidence is only one lever in the process of bringing about change, and it needs to be applied at the right point and in the right way in an organisation to be effective. This does not mean that we should give up on it, but that in our quest for quality improvements in health care we should also start to look much more seriously at how change is effectively achieved in organisations. G K Chesterton, a devout Catholic, once described Christianity as having: "not been tried and found wanting; it has been found difficult and left untried."5 While I would hope that the same fate does not ultimately befall evidence based medicine, the evidence so far does not convince me that it won't.
Competing interests: None declared.
References
Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials. BMJ 2004;329:
Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Variation in use of video assisted thoracic surgery in the United Kingdom. BMJ 2004;329:
Plous S. The psychology of judgement and decision making. New York: McGraw-Hill, 1993.
Timmermans S, Berg M. The gold standard: the challenge of evidence-based medicine and standardization in health care. Philadelphia: Temple University Press, 2003.
Chesterton, GK. What's wrong with the world. New York: Dodd, Mead, 1910.(Peter McCulloch, reader i)