Letters

Parachute approach to evidence based medicine: Summary of other responses

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7572.807-b (Published 12 October 2006) Cite this as: BMJ 2006;333:807
  1. Birte Twisselmann, assistant editor (web)
  1. BMJ

    The article by Potts et al sparked heated international debate.1 Many took issue with the parachute analogy, which they perceived as flawed, inappropriate, superficial, outdated, or mere sophistry—although only a few correspondents mentioned that it had been taken from a spoof article.

    The ethical aspect of randomised controlled trials was mentioned as important for patient safety. Many understandably criticised the fact that the authors had chosen resource poor settings to illustrate their point, and not only because this implies discrimination or double standards. To cite Lelia Duley, professor of obstetric epidemiology in Leeds, “the appropriate evidence can potentially have even more dire consequences in poor countries, where health services resources are even more scarce and overstretched than in rich countries.” And many cited examples to illustrate where “good science” without trials had not had the desired good outcomes. Two out of the three interventions used as examples were criticised on grounds of their effectiveness. Simon Gates, principal research fellow at Warwick Medical School, thought that the authors cited literature selectively for all three examples and had not based their conclusions on an overview of the evidence.

    Two respondents wholeheartedly agreed with the authors. David Hawker, a retired general practitioner/anaesthetist from Bodmin, thinks we have become “star-struck” by the need for randomised controlled trials and that this thinking may “severely hinder the good.” And A Breck Mackay from Australia criticises evidence based medicine itself in its current form as faulty owing to underlying assumptions that need to be re-evaluated.

    Others agree with certain aspects of the reasoning in the article. Gautham Suresh, associate professor of paediatrics in the United States, is among those who maintain that it is crucial always to use the highest level of evidence in choosing interventions and be explicit about this choice, but he agrees with the authors in that “one should not always wait for the highest possible evidence before acting.” This point of view is largely supported by Oliver Boney, senior house officer in general medicine in Luton, who emphasises that randomised controlled trials remain the gold standard of evidence based medicine precisely because of the inherent unreliability of observational studies.

    Miles Witham, clinical lecturer at Dundee University, concludes that the authors have made a compelling case for more controlled trials, not fewer—and the sooner the better. And while Matthew Green, senior house officer general surgery in Frimley Park, agrees that some treatments may need to be introduced without the benefit of full randomised controlled trials of effectiveness, he points out that this throws up questions about accountability, authority, and follow-up.

    Oxfordshire general practitioner Richard Lehman in his journal blog on bmj.com concluded: “This article is so bad it may actually do some good.”2 Enough said.

    Footnotes

    • Competing interests None declared.

    References

    1. 1.
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