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LETTERS: David I Tovey Evidence is important but should not be the only consideration: patients' and clinicians' views matter too BMJ 2007; 335: 952 [Full text]

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Evidence and opinion

Roger A Fisken   (11 November 2007)

The nature of evidence

John Toby   (15 November 2007)

Re: The nature of evidence

David I Tovey   (21 November 2007)

Evidence and opinion 11 November 2007
Roger A Fisken, Consultant physician Friarage Hospital, Northallerton, DL6 1JG Send response to journal: Re: Evidence and opinion	I really do not understand the statement in Tovey's letter when he says: "a principle of evidence-based practice is that the evidence should be [considered] alongside the perspectives of both patients and clinicians". I also disagree with his statement that "an evidence-based service should reflect expressed patient preference". Surely the whole point of evidence-based medicine is that it provides objective support for a particular type of practice unrelated to clinician or patient opinion? For years clinicians believed, and taught, that women must stay in hospital for a week after giving birth until the evidence made it clear that this was unnecessary and possibly dangerous. As far as patient opinions are concerned, perhaps Tovey is too young to remember the laetrile controversies of twenty-five or so years ago, when U.S. parents of children with cancer were taking all manner of legal and extra-legal measures to force doctors and insurers to provide laetrile treatment for their children despite the fact that it was utterly worthless and probably harmful. As regards homoeopathy, it really is time that this archaic mumbo- jumbo was confined to the dustbin of history where it belongs. Not only is there no respectable body of evidence for its effectiveness but the junk science of 'water based memory' and 'potentisation' on which it is said to rely is, in the era of magnetic resonance imaging, demonstrably false. The fact that patients may believe in homoeopathy is not, in any sense, evidence for its value and certainly not a reason why the NHS or any other publicly-funded body should support it. Patient opinion is obviously crucial in the planning and delivery of any proper medical service but it is not evidence: if Dr Tovey cannot tell the difference between opinion and evidence then I fear for the future of of BMJ Knowledge. Competing interests: None declared
The nature of evidence 15 November 2007
John Toby, General Practitioner Chinkwell House, Great Brington, Northampton NN7 4HY Send response to journal: Re: The nature of evidence	I am interested and disturbed by the fact that Tovey (although, of course, not alone) makes a distinction between 'evidence' and 'patients' views'(1). While understandable in a very narrow context, this usage reveals a continuing and important attitude. A judgement does have to be made about the weighting given to different types of evidence but to deny that description to the views of users seems to defy the normal use of language and their interests. To be fair, Tovey does recognise the value of patients’ experiences later. However, if the views of patients and members of the public were obtained, understood and given appropriate weight as part of the routine analyses of ‘evidence’, many decisions about health care might be much more soundly based. 1. Tovey DI. Evidence should not be the only consideration: patients’ and clinicians’ views matter too. BMJ 2007;335:952. (10 November.) Competing interests: None declared
Re: The nature of evidence 21 November 2007
David I Tovey, Editorial Director BMJ Knowledge, BMJ Group Send response to journal: Re: Re: The nature of evidence	I am interested to note that responses to my initial letter divide on cultural lines (albeit n=3!). Dr Toby, as a GP, points out that patient choices and preferences are a form of evidence. I agree that this can be the case and that perhaps I would have been better to use the term "research evidence" in my original letter. From the other side of the fence, Dr Fiskin, a Consultant Physician, seems to question whether patient preferences have any part to play in an evidence based world. To this I can only quote from the "User's Guide to the Medical Literature" which quotes as a "Fundamental Principle of EBM" that "Clinical Decision Making: Evidence Is Never Enough" and goes on to say "decision makers must always trade the benefits and risks, inconvenience and costs associated with alternative management strategies, and in doing so consider the patient's values." [1] One can only assume that this includes patients whose values are different from their doctors? Whether or not complementary and alternative therapies of uncertain value should be available on the NHS is a different and difficult question, but all I was attempting to say was that a) ignoring patient preferences is not a feature of EBM, and b) it is feasible to submit such therapies to fair testing. Patients would be as interested as the rest of us in the results. [1] Users' Guides to the Medical Literature: A manual for Evidence Based Clincal Practice Ed Guyatt G, Rennie D. Published by JAMA 2002 p5. Competing interests: I am Editorial Director for the BMJ Knowledge division. We are responsible for producing evidence bsed products for clinicians and the public.