Dr. AP Swart, EC Medical Officer
New Somerset Hospital
Cape Town

How many times have we been told to rather do A instead of B because of some study or other? Just the other day I attended ACLS and was told that nowadays family is supposed to hang around the resus attempt, because some studies showed this to help grieving. My immediate response was “What?” This seemed absolute nonsense. My incredulity apparent, one of the other participants was dismissive of my lack of belief, saying with an unbelievable air of condescension “studies have shown”.
This is indicative of the silly trust placed in those words.

Take this example. How do you quantify grief? Is not every instance different? Does not the death of your grandfather differ from that of your child? Is this not horribly subjective? Such studies would of course consist of questionnaires and hypothetical extrapolation, along the lines of “if you had been there, would it have helped you accept his death?” One cannot line up a group and arbitrarily allow family presence in one resus and then throw them out another to compare with any useful data. The only way to test this would require holocaust level cruelty; as how can one set up a control of any meaning unless we kill off another family member to compare the ensuing grief, but even this data would be tainted. There is simply no logical way for any evidence to be gained that does not simply equate to pure opinion and extrapolation on specious grounds. Yet this is presented as “studies have shown”, as a fait accompli. Such words are bandied about as golden calves to be worshipped, as if we are meant to cower in awe at the sacred wisdom presented to us.

Studies have their place. EBM is a useful tool. It is however a tool – a heuristic technique, a method of ascertaining what path to follow. It is not gospel, they are not truth. A good example of what I mean is with the anti-vaccine movement.
In 1998 the journal the Lancet published a paper linking Autism to MMR. This is a respected journal and the data appeared sound and definitive. If we practiced Evidence-Based care in 1998 we would be justified in not giving MMR to children or at least weighing it against the risk of Autism vis-à-vis Measles, Mumps and Rubella. Yet all of this was fraudulent, the author of the paper a huckster and subsequently no link has ever been shown. Yet now we are stuck with a raving anti-vaccine movement and people disrupting the required herd immunity. They materialised when media trumpeted this ‘Truth’ when the study had been published and once such opinions crystallised, they are difficult to dislodge. The study in a respected journal was enough that subsequent studies and expert opinion are written off as conspiracy or farce. This idiocy has now come home to roost with measles outbreaks worldwide and the root cause lies in the gullibility of “studies have shown”, it seems to be a shibboleth in the medical community today.

Then there is the arcane nature of EBM itself. It is a creature of statistics, which as Benjamin Disraeli probably said: “there are three types of lies: Lies, damn Lies and Statistics.”
EBM uses confidence intervals and complicated meta-analyses to present to us what conclusions should be given more or less weight. Few doctors have the time or the inclination to follow up this data that was used to reach these conclusions. We assume that they are fair, that they were diligently done. We simply have to take them on trust, as medical consensus, yet often this trust is taken too far and we end up with the position where such ideas are treated as proven.
Recently a large study called CHEST was done that addressed the colloid/crystalloid debate. When it came down thoroughly in favour of crystalloid we saw medical organisations summarily eject all their starches, outright bans in places. This was throwing the baby out with the bathwater, an egregious overreaction. Colloids still had their place and subsequently on review the bans were misplaced as the negative outcomes were more in septic patients. Throughout the country some places bowed and prayed to “Studies have shown” and threw out their colloids, while other more prudent departments waited to see what happens when the dust settled while hoarding their colloids for a rainy day. I remember a heated discussion between Anaesthesia and ICU on this very subject at the time.

This merely shows why we must be careful. Why we must perhaps take hype with a pinch of salt until we can read the packaging and see for ourselves. We are taught Medicine at the feet of consultants and older doctors, standing on the shoulders of great physicians of the past and as we move forward we must sieve through new information, keeping what we had been taught or jettisoning where appropriate and in future we shall pass on the Art to the next generation. We are the link that either progresses and propel us forward or causes stagnation. We cannot test everything, but we simply cannot blindly trust either. It is a tightrope of critical thinking, a golden mean we must tread. When presented with a conclusion far beyond the pale, we need to investigate; we need to deconstruct the aim and conclusions reached. Never must your reason rest; never must we treat a study as Revelation.

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