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EDITORIALS: Iain Chalmers Confronting therapeutic ignorance BMJ 2008; 337: a841 [Full text]

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Human nature seems averse to evidence

Arun S. Nanivadekar   (18 July 2008)

Research effectiveness

Brian S Buckley   (3 October 2008)

Human nature seems averse to evidence 18 July 2008
Arun S. Nanivadekar, Medical Research Consultant C-2, Flushel Apts, 21 Road, Bandra (W), Mumbai 400050, India Send response to journal: Re: Human nature seems averse to evidence	The last sentence of Sir Iain's essay[1] emphasizes the role of patients and the public in helping doctors to confront therapeutic ignorance. However, seeing the increasing popularity of alternative and/or complementary medicine (ACP) everywhere, I believe modern medicine will fail to confront therapeutic uncertainties unless its practitioners offer their patients what they need most as human beings in distress: time, empathy, and understanding. This is one area in which practitioners of ACP seem to score clearly over those of modern medicine. Besides, as Brown[2] has pointed out, a successful medical man has to exhibit supreme confidence and decisiveness at the patient's bedside whereas a physician- scientist (trying to confront uncertainties) is likely to present a picture of diffidence and self-doubt. Brown says, "Medicine and science require complementary thought processes; the processes that work for one are devastating for the other." If this is so, then we need two kinds of physicians: one, those who will confront uncertainties and try to resolve them; and two, those who will accept and adopt the advice of the former with trust and confidence. Alternatively, our medical education system must train doctors in alternating successfully between rationalism and empiricism throughout their career. It in for such an endeavor that the psychology of patients and the public comes into play. This reminds me of a rare book by Dudley[3], which emphasizes the importance of language, logic, psychology, and statistics in medicine as much as in all other walks of life. Despite these predicaments, I prefer to be hopeful. Arun Nanivadekar, MD MSc 1. Chalmers I. Confronting therapeutic ignorance BMJ 2008; 337: a841 2. Brown MS. The making of a physician-scientist; 2000. In, Grossman DC, Valtin H, ed. Great issues for medicine in the Twenty-first Century. Ann N Y Acad Sci 1999; 882: 247-256. 3. Dudley SF. The Four pillars of Wisdom. London: Watts & Co., 1947. Competing interests: None.
Research effectiveness 3 October 2008
Brian S Buckley, Cochrane Research Fellow Department of General Practice, National University of Ireland, Galway Send response to journal: Re: Research effectiveness	Sir Iain Chalmers once again directs the spotlight onto an issue of core importance in medicine and health research(1). Much is heard of clinical effectiveness and cost effectiveness in health care, less of research effectiveness. Yet medical and health services research may be failing both clinicians and patients alike by neglecting to address the most important areas of clinical ignorance and uncertainty. Concerns have been expressed previously that much of the clinical research conducted each year does not address the questions about treatments that are of practical importance to patients, their carers and the practicing clinicians to whom they turn for help(2, 3). Nearly ten years ago a study highlighted this mismatch between what had been researched and the information that the clinicians and patients felt was needed to inform everyday treatment of osteoarthritis of the knee(4). Sir Iain suggests that the failure of medicine and health research to acknowledge and confront uncertainty about the effectiveness of treatments can result in widespread suffering and death of patients(1). But how can research best ensure that it is targeting its efforts and resources most effectively? One approach is that encouraged by the James Lind Alliance in which working partnerships of patient, carer and clinician organisations work together to identify gaps in the evidence which are of day to day clinical importance within specific clinical areas and to prioritise these in order to influence and inform the research agenda(3). Such working partnerships are ongoing, sustained largely through the enthusiasm of patient and clinician organisations in specific disease areas(5). Research ineffectiveness can only make the challenge of addressing the need to increase public engagement with and understanding of health research all the more difficult and add to the difficulties posed by increasing research regulation. If the effectiveness of health research is to improve, we must ensure that we listen to the voices of the patients and clinicians who struggle daily to make important decisions with insufficient evidence and direct our efforts and resources accordingly. Competing interests: Voluntary Chair of the Board of Trustees of the UK Bladder & Bowel Foundation, currently engaged in a James Lind Alliance working partnership identifying research priorities in urinary incontinence.