Wise old men
In her shortlisted essay for the 2018 John Henahan Prize, Dr Joséphine Behaegel says there's nothing like being certain you're doing the right thing
Not too long ago, medical decisions were based on opinions. Wise grey old men with big moustaches would teach what wiser, older men had taught them. Over time, critical thought and the scientific method crept in. The “eminence-based” medicine of the past made room for “evidence-based” medicine.
The role of the doctor changed too. It shifted from the healer to a strange multitasking creature. Doctors of the past built a doctor-patient relationship. Today we are forced to manage not only patient relationships but the doctor-administrator, the doctor-computer and — often the most feared — doctor-research relationship.
One day a week, I shift from my normal job as a clinical researcher back to a physician with a full day of clinic, including screening for cataracts. Patients ask questions like ‘What would you do?’ ‘Which option would you choose?’ and the classic ‘Well you’re the doc, you tell me’. As resident in training, I often feel insecure and wonder how best to guide them. Is the cataract bad enough for surgery to warrant the risks? And if it goes wrong, did I push them too hard?
It can seem that “average” outcomes have become the new “failure”, and failure is the stuff sleepless nights are made of. As a relatively inexperienced resident, the best armour for this insecurity is to know that you are at least practicing some evidence-based medicine.
The randomised control trial (RCT) sits at the heart of evidence-based medicine. RCTs have a design that is more powerful than other study types. They have the potential to suppress our own bias and are — at least theoretically — the ideal tool to guide physicians towards the answers they’re looking for.
RCTs are great! So why don’t they inform all of our decisions?
I am a clinical scientist 80% of my time and I see the problem from a different perspective. I started my research in 2015 when my “Big Bang Theory” enthusiasm was at its peak. I had some fun and geeky moments when the first positive results rolled in, but I soon realised that clinical research is not all kittens and rainbows. It’s work. Often unglamorous and tedious work, and not really what I was trained in.
Each patient recruited comes with a mountain of documentation to fill in and it will get on your nerves faster than acanthamoeba from a dirty contact lens. The information needs to be checked by your own team, then checked again by an independent data monitor for quality. This makes RCTs very expensive.
Oh but wait, there’s more. After all the late nights and sweat-inducing research, when it’s f-i-n-a-l-l-y time to publish your data, the field has already moved on! So, go ahead and tell yourself that you probably gained a lot of life experience. And that’s almost as important as your h-index, right?
The question isn’t “do we need RCTs” in cataract surgery. We do. The question is “where do we even start?”. Cataract surgery is one of the most dynamic fields in medicine, where lenses, techniques and implants keep changing. Performing an unbiased RCT can take three-to-five years. How can you be sure that the outcome will be relevant?
And who will fund your RCT? As an example, an RCT comparing two lens implants should steer clear of industry funding. But who else can you ask when national and international research funds are busy trying to cure paediatric cancer? Even when you have your RCT off the ground, the pressure is so high to produce a paper that researchers can be tempted to fudge or cherry-pick their best results to get their work into the right journal. The end result is that we will never have RCTs to back up every situation, every patient and every decision.
Yet decisions have to be made every day. In these moments, apart from our role as clinician, scientist, manager and communicator, we must also act as human beings. We make bespoke plans guided by our perception of the patient, our intuition, and our reading of the patient’s expectations. So rather than being preoccupied with evidence, I prefer to think about the relevance and what the evidence can do to help me inform this person, right here.
And every time I prescribe a combination of topical NSAIDs and corticosteroids after cataract surgery, I am thankful to the ESCRS who stepped up and funded the poor souls who toiled away at the PREMED study. At least in this scenario, I can rely on the best evidence-based practice. There’s nothing like being certain you’re doing the right thing.
Dr Joséphine Behaegel is a resident in the University Hospital Brussels, Belgium and a researcher at the University Hospital Antwerp, Belgium