In 1976 two successful and respected medics, Archie Cochrane and Kerr L. White, were making a tour in New Zealand. White was about to address a group of clinicians in a major city hospital when he noticed their staid and stuffy demeanour. He suddenly decided that he did not want to startle them so he smudged his statistics a little. He said that about 15 to 20% of physicians' interventions were supported by objective evidence that they did more good than harm. He had wanted to say that the figure was only between 10-15% in fact.
These statistics were drawn from a survey carried out in 1963. Twelve general practitioners from practices in a northern industrial town recorded their expectations as they made their prescriptions during the course of two weeks work. They categorized them in the following way: those prescriptions expected to have the specific benefit intended: 9.3%; those expected to have a probable benefit 22.8%; those with a possible benefit 27.2%; and those which were hopeful 28%; 8.9% were prescribed for their placebo effect; and 3.6% simply defied any kind of expectation at all.
When you have the context of a set of statistics, you have a better idea of their truth-value. Twelve GPs recorded their ideas about the way they prescribed their medications during a two-week period in 1963. At this point, with the statistics situated in the network that produced them, it is still possible to take your bearings and make a reasonably sound judgement. I don't think there can be many people who can't laugh, or at least crack a smile, at the way we all get a bit dazzled by numbers. 9.3%, 27.2%, 3. 6%, - all those decimal points rather suggest a degree of precision that is indeed awesome. But 22.8% of 12 doctors jotting down their hunch about whether a drug is probably beneficial rather than possibly beneficial is a little less amazing. However, it is a lot more meaningful. If you can bear to give up a bit of the dazzle, the pay off can often be useful.
Cochrane and White seem to have been modest men who wanted people to know that they were aware of their limitations, that they did not possess the secret of life and death, but that they had to exercise their judgement against enormous uncertainty. One conclusion that might be drawn from the above information is that, modest or not, Cochrane, White and their colleagues were doing an important job. They deserved respect and reward from their contemporaries. A different conclusion is this: doctors are quacks and charlatans and don't really know what they are doing.
In between these two alternatives there is a question - can we know more about people and their illness? Can we understand better why doctors are left in the dark? This question has led to a flourishing of different kinds of idea and approach that include statistics, anthropology, psychoanalysis, psychosomatics, psychology, sociology and even poetry (for an excellent section of different approaches see Leader & Corfield, 2007). In the 1970s it led Archie Cochrane to write about randomised controlled trials. In the last 10 or so years the flourishing arts and humanities have suffered a baffling defeat - it is as if they have been struck down by a mysterious plague. Suddenly, seemingly out of nowhere, randomised controlled trials were declared 'the gold standard' for all kinds of medical and related research.
There's a lot more to be discovered about this, but I want to stay for the present with the man Cochrane. When he wrote his book he found that he had said all he wanted to say after the first couple of chapters. He was obliged, however, to pad it out to fill up the required number of pages. Writing last few chapters made him quite depressed. He had been asked to do the impossible - come up with a solution to the problem of medical knowledge on a national and ideological scale. He probably knew it was impossible but for some reason he couldn't give it up. He was being asked to move from the particular to the universal, and from the practice of medicine to that of management - on a national, political scale.
Back in the 1930s Archie Cochrane had gone to Spain to fight the fascists, and he had even gone to Vienna to undertake a training analysis with Freud. He said disillusionment led him to give up these ideological pursuits, and he joined the Army in time for the second world war. He was captured in Crete and spent four years in a German prison as the Medical Officer for the POWs, of which he says: "There were about 20,000 POWs in the camp, of whom a quarter were British. The diet was about 600 calories a day and we all had diarrhoea. In addition we had severe epidemics of typhoid, diphtheria, infections, jaundice, and sand-fly fever, with more than 300 cases of 'pitting oedema above the knee'. To cope with this we had a ramshackle hospital, some aspirin, some antacid, and some skin antiseptic. The only real assets were some devoted orderlies, mainly from the Friends' Field Ambulance Unit. Under the best conditions one would have expected hundreds to die of diphtheria alone in the absence of specific therapy. In point of fact there were only four deaths, of which three were due to gunshot wounds inflicted by the Germans." (from page 5). What explains this extraordinary survival rate? With such a stunning scenario it is not difficult to begin to think about spirit and to start talking about love. Archie Cochrane can inspire love from his fellows, and can invoke love for their country, and he can nurture a desire for survival. But he could also get side-tracked by big ideological ideas.
We can't hold him responsible for the current fashion of EBM, but we can wonder why his name has dropped out of the frame. I wonder why the National Institute for Clinical Excellence hasn't erected a statue in his honour - they prefer to carry on as if the idea had come directly from god. In fact, this might be more true than it at first seems. As I have already noted elsewhere (Low, 2007), Archie Cochrane himself has pointed out how the ideas of EBM were quickly taken up in the protestant countries, and were much more slow to gain hold in the communist and catholic countries (op cit p 24). I'm not putting forward a religious doctrine, and I doubt very much whether Cochrane was. I am more inclined to go off to re-read Max Weber to get a perspective on this. But even without a detailed sociological disquisition, it is possible to think that the wish for a trouble-free truth is what pushes something like NICE (and the governments who hope to gain from it) to prefer to suppress the nuisance of different paradigms of thought.
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Cochrane, A L (1972) Effectiveness and efficiency; random reflections on Health Services. Nuffield Hospitals Trust, reprinted by Royal Society of Medicine Press 2004
Leader, Darian and David Corfield, 2007, Why do people get ill? London, Hamish Hamilton
Low, Janet, 2007 Power, Authority, Validity: the IAPT/CBT Nexus. Guest editorial eIpnosis 9 Nov 2007.
