In praise of informed scepticismBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3980 (Published 19 June 2013) Cite this as: BMJ 2013;346:f3980
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The article Why we can't trust guidelines--together with the other two articles in the same edition of the journal, Restoring the integrity of the clinical trial evidence base, and Restoring invisible and abandoned trials: a call for people to publish the findings--are timely in relation to the current culture of evidence based medicine.
Clinical trials and guidelines are dominating clinical practice at the moment.
This thinking needs constant scrutiny and these three articles provide that, but much more and on going attention is needed.
An example of the shortcomings of clinical trials is the surprising frequency with which patients are excluded from the major COPD trials(1,2)
-Many trials exclude non-smokers despite the fact that many patients with COPD do not have an adequate smoking history.
-Patients with reversibility are excluded despite the fact that reversibility is very common in COPD.
-Older patients are often excluded from clinical trials and this despite the increase in frequency of airways disease with age.
Further examples for excluding other patients exist, and it is likely that fewer than 1 in 10 patients with COPD are eligible for inclusion in major clinical trials(3)
Again the worry is the influence of the pharmaceutical industry which largely finances the clinical trials and of course the clinical guidelines that flow from the clinical trial conclusions result in considerable revenue for the pharmaceuticals.
That so many categories of patients with this heterogenous condition have in fact not been tested in the large clinical trials undermines the authority of the COPD guidelines which in any case create their own difficulties(3)
Guidelines have resulted in unintended consequences, the care of these patients has largely shifted to the nurses under the incorrect assumption that all that is needed is to follow the guidelines, the further consequence being that the GPs have tended to become de-skilled in the management of these patients.
Evidence based medicine has its place in modern medicine but on going care is needed over the evidence.
(1) PG Gibson, JLSimpson.The overlap syndrome of asthma and COPD:what are its features and how important is it? Thorax 2009;64:728-735
(2) Richard Beasley, Mark Wetherall, Justin Travers, Phillippa Shirtcliffe. Time to define the disorders of the syndrome of COPD Lancet.2009.Vol 374:670-72
(3) Rod Storring. Why do GPs find management of airway diseases difficult? Prim Care Respir J 2011:20(3) 237-8
Competing interests: No competing interests