This is a magnificent and brave book. It demands full support, and I am bold enough to express this. It brings together knowledge which many of us in medicine have known for some time, but it makes clear that the problem is worse than we have realised.
This book strikes a fundamental blow to medical epistemology. We used to joke that "Half of what you learn in medical school will be of no use to you in practice- the problem is just that we don't yet know which half; After reading this book you realise the problem is deeper- too much medical knowledge is suppressed from the start- and so as doctors we do not even know what we don't know. It just never crosses our consciousness. We don't even know the half of it.
The flaws in medical knowledge Goldacre describes run wide and deep.
Too much medicine is simply never published or recorded.
Negative results "This does not work" are just as important to medical practice as "this does work." Yet routinely negative studies are ignored, filed away, unpublished, maybe never even written up. There is no journal of failed treatments and other false starts. Authors and researchers don't get promoted for showing such results. Share prices don't rise on such news.
Too much pre-selection and pre-editing goes on so that what reaches large journals and is then available to be incorporated into guidelines is rather over-optimistic, and based on a biased sample. (Most of the times a drug hasn't worked in a clinical trial the information simply vanishes into "internal company files") Goldacre points out how unethical this is- patients have been taking part in clinical trials to advance medical knowledge- and then the trial goes unpublished so no one can learn from it. Worse still some patients are at risk of harm as a result of this omission.
The way information is presented to and by journals is biased. Large positive results are welcomed by drugs companies and journals alike- good for sales of both of them. Good for authors too. (Kudos/promotions) Some doctors put their names to articles they have barely even reviewed.
Many trials are stopped too soon- so long term treatments are assessed over unrealistically short time scales. Many trials stop too soon so that later complications are missed out of the analysis.
Many trials are set up against false or misleading comparators, rather than against best current treatments.
Many journals are not robust in their peer review processes, and the possibility of obviously misleading flawed papers reaching publication (and so the credibility that goes with that) is huge. Peer review is touted as a gold standard of academic accuracy yet in reality it shows that fools seldom differ, and that great minds think alike. The misuse of reviewing by some competitive scientists to advance their own views, and to do down competition, rather than quality assure scientific results, is a blot on science's copy book. (I do peer review for some journals and sign my name to reviews- and try to be fair about a paper's merits)
National Regulators are not given the full information about candidate drugs, and have no means to compel its production. So they make their assessments of a drug's merit on partial and positively skewed information. Bodies like NICE then have incomplete information on which to base their recommendations. All the way through the deletion and distortion of the published record of medicine is weakening our ability as doctors to make good treatment recommendations to our patients. We do not know either the positive results or the negative results properly, and so no one can get a proper overall view of which drug is good for which patients. The potential for harm by ignorance is huge here- whether by missed benefits or unrecognised side effects.
All this means that the medical information data base is skewed, distorted and misleading. As a doctor I try to practice evidence based medicine, and act in accordance with current assessments of best practice. What this book confirms is that my efforts are undermined before I start- all the information I need is not available at any stage of the process. I could be superbly read and up to date- and yet because of the flaws in the medical evidence base simply be moving deeper into misleading myself, and consequently my patients.
This is not a comfortable realisation. The medical information base, that can then be consolidated into reviews, guidelines, the BNF, and text books is utterly flawed. The prevalence of deletions (missing information) and distortions (spin, misleading presentations of data) mean that my personal and our collective knowledge is inaccurate right from the start.
And that's before my own prejudices and misunderstandings can even get going. Some years ago a post graduate tutor asked me to lead an EBM workshop and describe the process whereby we as doctors come to understand the evidence and then digest it and present it fairly to patients. I said I very much doubted that doctors do understand evidence very well themselves- we are easily misled by presentation effects- just as everyone else is. Ultimately the analysis of medical evidence is largely by means of detailed statistics, and few doctors understand these well. A patient of mine who was a statistician told me that his first question to a client was , "what do you want these statistics to show?" He could then work to their wish. Numbers do not speak for themselves, but can be made to sing sweetly if played right.
This book shows that the current systems of discovering new medical knowledge, and of using existing knowledge well, are severely flawed. This is not a good state for my profession to find itself in. We have grand edifices of knowledge, and this book shows that many of them are built on sand. For a profession that prides itself on being based on accurate, well defined and described knowledge this is a very poor performance.
Goldacre's book is important and raises significant questions about what we are doing as doctors, and about how we get the information we need to practice medicine well. This book shows that there are currently very widespread deep problems at every stage in the generation and distribution of medical knowledge.
His book is well written, well exampled and accurate. It should compel action by many people in medicine, the pharmaceutical industry and by those around medicine who regulate knowledge generation.
This is an important book, and it is vital for doctors to read it, no matter how uncomfortable its implications are for us.
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Top reviews from other countries
- VirgilReviewed in the United States on 19 September 2016
Never be fooled by so-called "evidence based mumbo jumbo" ever again. (And see Jesus and George Carlin at the end of this)
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Plinio José Cavalcante MonteiroReviewed in Brazil on 18 July 2015
Um livro fascinante!
