On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 n.1 Cape Town Jan. 2008
PO Box 6299 Rustenburg Dirk@Hagemeister.net
To the Editor: Your editorial1 in the SAMJ, and Dr Sanders' response,2 evoked an interesting discussion about whether 'evidence-based medicine' (EBM), based on randomised controlled trials (RCTs), can answer all our needs in medicine. Medicine (for me) is a profession that requires the practitioner's heart, brain and hands.
The 'scientific brain' is sometimes under-represented in medical discussions (I would not dare to guess how many undergraduate medical students or graduates aren't properly able to interpret data). It is obviously not enough to perform medicine only with the heart - we need proper scientific and mathematical skills - otherwise voodoo-like approaches to the HIV/AIDS pandemic (beetroot, sweet potatoes, etc.) should not surprise us. Medicine needs a properly regulated course of training, registration and a sound scientific approach towards acquiring the knowledge that can be applied to individual patients. Western medicine has gone a long way to arrive at this point.3,4
But this theoretical and structural framework comes at a price. An undeniable and already clearly recognised shortfall in this type of modern 'Western' medicine is its tendency to reduce humans ontologically to a 'manifestation of general biological, psychological and sociological theories'.5 The 'patient' is no longer perceived as a unique entity with an incomprehensible depth of being. Instead, the 'suffering other' is converted into a 'case'.
The theoretical concept underlying RCTs is the fundament of this reductionist approach: Patients, diseases and therapies must be strictly categorised and inclusion and exclusion criteria defined.6 RCTs play an important and indispensable role in EBM; for methodological reasons, no reliable statement can be made about the usefulness ('effectiveness') of a given drug or intervention without RCTs. But ought the practice of EBM to be as reductionist as RCTs? Should patient care merely consist of the proper categorisation of the patient according to identifiable attributes and then the application of the most appropriate algorithm-determined therapy? There is more to EBM than statistical evidence: 'The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research'.7 Physicians need to understand that the art of medicine consists of more than pure reason.8,9 We have to live with our fears and frustrations and the limitations of our medical skills, which we have to communicate to our patients. 'Take this antibiotic' is easy to communicate; but 'I don't know what you are suffering from', 'There is no known cure for your disease' or 'Your child is likely not to regain consciousness' are more challenging; they challenge the physician as a human being. 'I don't know' and even 'I have failed', which is part of every human life, need to be recognised as a fundamental part of modern medicine, in the same way as RCTs are recognised.
I close with the third body-component. Hearts and brains are needed in medicine (as stated), but so are the hands - an undeniable experience for somebody who studied at a theory-loaded and practice-deprived European medical school and was later confronted with the 'hands-on' practice of South African medicine.
1. Ncayiyana D. Evidence-based medicine is not all randomised controlled trials and systematic reviews. S Afr Med J 2007; 97(1): 7. [ Links ]
2. Sanders FN. Controlled trials - thinking the unthinkable? S Afr Med J 2007; 97(5): 310. [ Links ]
3. Burrows EH. A History of Medicine in South Africa up to the End of the Nineteenth Century. Cape Town & Amsterdam: Balkema, 1958. [ Links ]
4. Starr P. The Social Transformation of American Medicine. New York: Basic Books Inc, 1982. [ Links ]
5. McWhinney IR. Clinical method. In: McWhinney IR. A Textbook of Family Medicine. 2nd ed. New York & Oxford: Oxford University Press, 1997. [ Links ]
6. Beaglehole R, Bonita R, Kjellstróm T. Basic Epidemiology. Geneva: WHO, 1993. [ Links ]
7. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996; 312: 71-72. [ Links ]
8. Horkheimer M, Adorno TW. Dialektik der Aufklärung. Philosophische Fragmente. 16th ed. Frankfurt am Main: Fischer Taschenbuch Verlag, 2006 . [ Links ]
9. Popper KR. Wissenschaftliche Reduktion und die essentielle Unvollständigkeit der Wissenschaft. In: Popper KR, ed. Alles Leben ist Problemlösen. Über Erkenntnis, Geschichte und Politik. 9th ed. München: Piper Verlag, 2005 : 47-92.