Book review: Testing treatments - better research for better healthcare. Evans et al
Testing treatments - better research for better healthcare. Imogen Evans, Hazel Thornton, Iain Chalmers. The British Library. 2006. ISBN 0-712-3-4909-X. 116 pp; Cost £12.95.
An
awful lot of people are going to get cross when they start reading this book,
but they should persevere, because they will end up agreeing with its most
important thesis.
The
start would not appear in any anthology of strategies on how to win friends and
influence people. The stark message seems to be that medicine is crap, doctors
and pharmaceutical companies are to blame, and the rest of us are spinelessly
complicit in letting it happen. None of which is softened by some 1980s
anecdotes from Nick Ross, an ex TV presenter. The first few chapters will have
you screaming at the book much as you would when listening to a government
lickspittle on TV telling why the NHS is better now than it ever has been. Yes,
but.... will utter from your lips time and again.
You
will feel, with some justification, that many criticisms are unfair, in large
part because they are commonly known examples from medical history. Things that
happened in the 1950s, or 60s, or even 90s may be recent in a common historical
context, but the pace of change in medicine has been so rapid that they could
be regarded as Jurassic. Bandolier well remembers pointing out Sir Hans Krebs
(yes, of the Krebs cycle) to some visitors in the early 80s, just before he
died. They thought that he had died in the previous century! Or the example of
a famous clinical pharmacologist boasting that it was his discipline's 16
th
birthday.
You
will feel, with some justification, that there should have been more of an
attempt to balance the problems with the successes, not just in therapy, but in
process. How much better would have been a discussion of the failures of
clinical trials and the subsequent development in their regulation and
monitoring. What an opportunity lost, to explore the benign tyranny of
regulatory bodies like the FDA over what gets done in clinical trials. How
about a debate over individual patient response and the absolute requirement
for "me-too" medicines, rather than thoughtless dismissal?
All
this will pass through your mind in the early part of the book. Indeed, such
will be their intensity that you will consider discarding it, or putting it
down for another day that never comes. Don't: complete it at a single sitting.
The
first two thirds, you see, serve as a form of quality control, which is about
discovering how bad things are. Looked at in that light, the authors are
surprisingly humble. There is much more that could be said about how bad things
have been and are now. There is much to be raged at. The final third is where
the payback comes, all about making things better. Of course, they can't
say everything about making research better in this one slim volume. For
example, we know that clinical research in the UK is dying on its feet, a
situation as bad or even worse than that portrayed in a recent Lancet editorial
[1].
The
authors want to have more public and patient participation in clinical
research, and provide a number of interesting examples where this has happened.
And where it has, it has led to better research, with more relevant outcomes,
better language, and greater participation by patients themselves who become
not only involved but also informed. They have a blueprint, the key points of
which are:
- Encourage honesty when there are uncertainties about the effects of treatments
- Confront double standards on consent to treatment offered within and outside clinical trials
- Increase knowledge about how to judge whether claims about treatment effects are trustworthy
- Increase the capacity for preparing, maintaining, and disseminating systematic reviews of research evidence about the effects of treatments
- Tackle scientific misconduct and conflicts of interest within the clinical research community
- Require industry to provide better, more complete, and more relevant evidence about the effects of treatment
- Identify and prioritise research addressing questions about the effects of treatments which are deemed important by patients and clinicians
It
is probable that even writing down these points will make some people cross.
Many will ask whether that's all there is? They will point to the fact
that anyone trying to get research funds under point 7 is almost certainly
doomed to failure. And who pays for all this? Not industry, because it's
not their problem. Not government, because it is stupid. Perhaps, on a good
day, downhill, and with a following wind, we might get a nibble from a small
charity, but they really want cures, which means test tubes.
None
of which matters. Or rather, it does matter, but it's not the point,
which is that there are better ways of doing things than we sometimes do them
now, and if it is possible to do things better, we should try to do it.
Many
of you will hate this book, and the more you know about clinical research, the
more you are likely to hate it. The more you are likely to hate it the more you
should read it. It will stir you up, which is what, perhaps, the authors
intended. For this reader, job done. Let's have some more polemics about the
practical and funding problems of clinical research, how important it is, and
what is being lost.
Reference:
- PM Rothwell. Funding for practice-oriented clinical research. Lancet 2006 368: 262-266
