cultivated in the traditional medical education concept " clinical
Thinking "does not mean clear and holistic vision of healing and is based
on analogies, largely in the form of anecdotes from the lives of the great doctors and manuals
take an example from the "elders." At the turn of 80-90-ies in English
Medicine has formed a new area of expertise - clinical epidemiology. Greatest
known are the work of Canadian scientists - D. Sackett, B. Haynes, G. Guyatt
and P. Tugwell from McMaster University, Ontario, the first attempt to consider
medical skill in terms of strict scientific guidelines 1. These scientific
principles and had a great impact on the style of medical practice
and outlook of doctors in the West. Unfortunately, until recently
Our doctors were not at all familiar with the new concept.
Clinical Epidemiology develops scientific basis for medical practice
- A set of asles for clinical decision-making. The central tenet of clinical
Epidemiology is: every clinical decision should be based strictly on
proven scientific facts. This postulate is called "evidence-based medicine",
literally - "Medicine is based on facts," or,moreaccurately
reflects the meaning of the term "evidence-based medical practice," or "scientific evidence
medicine. In order to answer the clinical problem your doctor may use
different sources of information and receive a variety of sometimes conflicting
facts and recommendations. Therefore, another important principle of evidence-based medical
practices associated with critical analysis of information: the "weight" of each fact is more
the higher the scientific method of investigation, during which the fact is received.
"gold standard" randomized controlled trials are considered.
Solo doctor's experience and opinion of experts or "authorities" are considered
as not having sufficient scientific basis. It is well known that only experiment
can show that science is tase. More carefully than he raised, the higher the probability
that his results are based on real-life relationship between the phenomena
and not an artifact and not a coincidence. Reproducibility -
one of the most important conditions for the objectivity of the data.
In contrast to the basic biomedical sciences, clinical medicine of interest
questions whose answers may provide research only on human beings, and
not in experimental animals, tissue cultures or cell membranes.
Clinical research is difficult to attribute to the "pure experiment". In fact,
here the object of study - a patient who is free to determine their actions,
while the experimenter - a doctor with a personal professional experience and inclinations, and sometimes
erroneous judgments.
That is why in clinical trials has always laid the danger of systematic
errors (bias), which can only be avoided by following a clear scientific principles.
In the most fully to these principles correspond to randomized controlled
clinical studies. They necessarily presuppose the existence of the experimental and control
groups of patients divided into groups at random (randomization), watching
at the same time that groups did not differ according to the parameters affecting the outcome.
physician-researcher, and evenmoreso the patient does not know whether the patient receives a placebo
or medication (double blind). All patients were traced during the
certain, often very long period of time (prospective study)
after which compares the rates of clinically important end-
points (recovery, death and complications) in the experimental and control groups. Often
to conduct similar studies involved tens of thousands of patients,
in different scientific centers and countries.
According to modern Western standards, no new method of treatment, prevention
or diagnosis may not be found without the mandatory scastiny in
randomized controlled trials. This approach differs greatly
from the Russian practice. So, in our country is quite widespread
is the method of hyperbaric oxygenation. In the analysis of 446 clinical papers
Application of this method showed that only 5.4% of them were a group of
control. None of the work was not carried out the randomization, no placebo was used
2.
Another example - the use of low-intensity laser radiation in the treatment of
number of internal diseases. Only 10% of 561 publications were control groups
1,8% of the cases used a placebo control. In this case, it remains unclear applied
whether at least one study randomization procedure 3. Our analysis shows
not the futility of these procedures and the lack of research-based evidence
their use. To the phenomena of this kind can be attributed, and method of diagnosis Foll,
and e ("Kremlin") pill. Any critically thinking person
This trend should be alert to the wide dissemination of unproven
scientific methods of treatment and diagnosis.
What is the cause of extremely low immunity of Russian physicians to questionable
diagnosis and treatment? Obviously, in the absence of a culture of critical evaluation
scientific publications and ignorance of the principles of evidence-based medical practice.
In an effort to fill this gap in the education of Russian doctors, publisher
Media Sphere "is preparing to release of a translation of the monograph" Fundamentals of Clinical
Epidemiology Harvard professor Robert Fletcher and Suzanne
Fletcher and a professor at Washington State University Edward Wagner 4. Other
our publishing initiative - is "International Journal of Medical Practice"
the focus of which will be a problem of evidence-based medical practice.
Why now, in the 90 years since actively talking about evidence-based
medical practice as a new outlook in medicine? The fact that each year
published the results of hundreds of randomized controlled trials
which alter the established standards of medicine. There is an inverse relationship
between the degree of awareness among doctors of modern methods of treatment and the number of
years after the end medvuza. It is quite clear that the good doctor wants to be
abreast of the latest achievements of medicine. And the fact that the questions arising
at the bedside, we must seek the answer in the medical literature, there is nothing
new.
New are evidence-based approaches to finding sources of information
and critical reflection. With the growing proliferation of new
information technologies (electronic databases and journals, and multimedia
training programs on compact optical disks and the Internet) expands
enable doctors to get the latest information, there is a need
understand the capabilities of these technologies to determine their place, role and relationships
with traditional print publications. Evidence-based medical practice
and clinical epidemiology are taught the art of critical analysis of medical information
and the ability to correlate the findings with specific clinical situation.
For the modern doctor's skills of critical evaluation is equally important and necessary,
such as the ability to auskultirovat patient. Many of the leading medical universities
? Process of
clinical decision-making doctor uses his understanding of the mechanism
illness and personal experience.
are often situations where neither the knowledge nor the experience is not enough, and then the doctor
enlists the aid ofmoreexperienced colleagues or experts in this matter, or
refers to the textbook. From the viewpoint of evidence-based medical practice
information used for clinical decision-making can be divided into
primary (original research data published in peer-reviewed
peer-reviewed scientific journals) and secondary (reviews and editorials,
Textbooks, expert opinion), direct (obtained in the course of clinical work) and
indirect (obtained in the experiment), the strong and weak (depending on the design
study). Evidence-based medical practice gives priority to primary
direct and strong information as a basis for clinical decision-making.
The fact that the textbooks quickly become outdated, and expert opinions are often contradictory
and it is unclear whom to believe. Sometimes the view once expressed by authoritative experts,
roams from one direction to another, despite the apparently contradictory
facts.
As an example, the recommendation for prophylactic
lidocaine in acute myocardial infarction. In 1974 he published an article under
that prophylactic lidocaine in the first two days of acute myocardial
infarction significantly reduced the risk of ventricular fibrillation, although it did not affect
mortality 7. Based on these data, the authors of the famous guide 'Disease
Heart, edited by E. Braunwald began to recommend routine prophylactic
lidocaine. (Interestingly, in this manual, including a third of its
edition of 1988 contains no mention of the lack of positive impact
lidocaine on mortality). This view has become almost an accepted and reproducible
in the vast majority of reviews and monographs until the early 90's.
This is despite the fact that by the year 1990 published the results of 12 randomized
controlled studies, and virtually all prophylactic
lidocaine in myocardial infarction led to an increase in mortality 8. Only
In the fourth edition of "heart disease", published in 1992, the authors acknowledged
tactics of routine administration of lidocaine erroneous and even harmful.
How to implement the principles of evidence-based medical practice? How exactly are
authors of the concept itself evidence-based medicine embodiment of the principles of evidence-based
medical practice in the real world 9?
example, consider the clinical situation: A patient enters the hospital
43 years undergoing an epileptic seizure for the first time in my life. From history we know,
that head injuries were not, the patient consumed alcohol moderately (1
- 2 times per week), on the day of seizure of alcohol is not consumed. At physical examination
abnormality is not detected. Computed tomography of the brain, too
found no pathology. When EEG revealed only nonspecific
changes. After intravenous loading dose of phenytoin (difenina)
The patient was transferred to oral medication. What is the further tactics
of the patient? Traditional approach. The attending physician consults
senior colleagues who have expressed the view that since the risk of re-
attack is quite high (although the precise degree of risk one can not call)
need to continue prophylactic administration of the dasg and monitored by a doctor at the place
residence indefinitely. The attending physician gives these recommendations to the patient,
prohibits him from driving a car and leaves him with a rather uncertain outlook
for the future.
science-based approach. The doctor asks what he knows about the forecast
after suffering a first epi-seizure, and realizes he does not know the answer. Then
He goes to the library, where does the query in the database MEDLINE. Same
thing he can do and using a personal computer connected
to the modem. Keywords epilepsy (epilepsy), prognosis (outlook) and recurrence
(Recurrent seizures), a doctor gets a sample of 25 abstracts. After studying them
it turns out that one article precisely matches the clinical situation. Physician orders
photocopy paper, from which recognizes that the risk of re-fit for
the first year ranges from 43% to 51% during the first three years - from 51% to
60%. If within 18 months after the first epi-fit repeated attacks
not observed, the risk is reduced to 20%. The doctor says this information to the patient,
recommending to continue taking the dasg and ask for a second consultation
and a half years to discuss the need for further medical
treatment. The patient leaves the clinic with a clear vision about its future, the attending
doctor feels an inner satisfaction in their work.
course, to the introduction of evidence-based medical practice is
many difficulties and barriers. G. Gyatt et al. 9 mark the most important. -
Most practitioners do not know the principles of critical evaluation of publications,
frightens them the complexity of mastering such skills. - People want quick and
simple answers.