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The Predicament

I recently came across this article from 1998 and was struck by its continuing relevance. It explains that clinical decision-making is not often supported by the best evidence available. We know that GP patients with all of their complexities are often not included in randomised controlled trials. Our clinical decisions take into account much more about a person’s total circumstance than can ever be articulated clearly through that kind of research.

The article bemoaning the lack of appropriate evidence seems even more relevant given the latest information with regard to meta-analyses and positive publication bias. The Reproducibility project tried to replicate the findings of 100 major psychological studies once it was recognized that positive publication bias may have inappropriately led to the acceptance of many treatments as evidence-based. Less than half of the trial results could be reproduced. This is not to say the results were wrong – but it does highlight the risk of only publishing positive findings. A similar path has been taken in Medicine, with efforts to ensure all data from clinical trials is published, regardless of the results. This follows on from groundbreaking research led by Professor Jon Juredini highlighting the misrepresentation of data in determining the efficacy of SSRIs for treatment of adolescent depression.

It is often argued that we are not asking the right questions in the research that is undertaken. For example, we continue to have a disease focus in research – finding a miracle cure for a disease is far more appealing to funders of research than investing into support for high quality primary care. When the GP Co-payment was initially announced in the 2014 Federal budget, it was going to fund the Medical Research Future Fund, to the tune of $20 billion. Was this fund going to be about general practice, service delivery and effective care models? No – it was going to be about diseases. This stance appears to have softened somewhat, but really – take away money from general practice to invest in research on diseases?

I believe that one of the issues we have in general practice is the complexity and scope of the issues and presentations we deal with. It is just not possible for non-clinicians to understand what it is we do every day. One may also argue the same is even true for our specialist colleagues. Perhaps this shouldn’t come as a surprise, but it means that if we want research that will be relevant for our patients, we have to do it ourselves.

In the meantime, the words of John Hoey, MD remain relevant;

In applying research findings at the bedside we need to make inferences that are logical and explicit. We need to think more and perhaps read less.”

Tim Kelly
tim.kelly@aogp.com.au