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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:

  1. Encourage honesty when there are uncertainties about the effects of treatments
  2. Confront double standards on consent to treatment offered within and outside clinical trials
  3. Increase knowledge about how to judge whether claims about treatment effects are trustworthy
  4. Increase the capacity for preparing, maintaining, and disseminating systematic reviews of research evidence about the effects of treatments
  5. Tackle scientific misconduct and conflicts of interest within the clinical research community
  6. Require industry to provide better, more complete, and more relevant evidence about the effects of treatment
  7. 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.


  1. PM Rothwell. Funding for practice-oriented clinical research. Lancet 2006 368: 262-266

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