Bank holiday Monday and I am signing off the Clinical Evidence chapter on burning mouth syndrome. On antidepressants, categorised with good reason as ‘unknown effectiveness’, the authors conclude:
‘The widespread use of antidepressants in burning mouth syndrome may be because of their effects on neuropathic pain, and the association of burning mouth syndrome with generalised anxiety disorder, depression, and adverse life events.’
In other words, despite there being no reliable evidence that any antidepressants help in this condition, they are commonly prescribed.
There could be no better example to illustrate one of the central themes of this important book — the importance of ‘fair tests’ to determine whether clinical interventions are effective. The three authors bring different but complementary expertise and experience from the overlapping worlds of evidence-based medicine, public involvement and research ethics. It is a readable, coherent and persuasive book and should become a standard within the practice library, of interest to clinicians from all backgrounds, but particularly trainers and registrars, for whom it should be required reading. Unusually, at least in my experience, Testing Treatments combines a surgical analysis of the challenges associated with providing patients with the best evidence on the effects of clinical interventions, with a blueprint for change. It is therefore both an authoritative learning resource and a rallying call to action.
What are the issues that should principally interest those at the primary care coalface? Firstly, of course the rather crucial question of whether treatments work or not and the various ways in which this message can be conveyed unreliably. Various examples of treatments that were thought to work but didn't and vice versa are described. Some of these will be familiar but the flow of the book expertly weaves them together into a coherent narrative. Among the most important themes are the importance of ‘tests’ that reflect the questions and outcomes that matter to patients, and the importance of identifying areas of genuine uncertainty. These reflect two of Iain Chalmers' passions and specifically his work in developing the James Lind Alliance to address the former issue (www.lindalliance.org) and the Database of Uncertainties about the Effects of Treatments (www.duets.nhs.uk) for the latter. Those doctors who cling to the idea that evidence-based medicine is a foe rather than a friend, will perhaps be persuaded by the following sentence, to think again.
‘… patients need to understand that if, having looked at the evidence, their doctor says “I don't know”, this is not the signal to seek a second opinion from another doctor who confidently says “I do know” while blatantly ignoring the prevailing uncertainty.’
Both patients and doctors are encouraged to be assertive in demanding that the research agenda matches their needs, and to take responsibility for ensuring that we increase our awareness about the effects of treatments. Testing Treatments also compares the ease with which clinicians can prescribe drugs outside their known and licensed indications, with the difficulty (probably justified) of getting ethical approval for a clinical trial. It made me think — how often did I, like the doctors described in the ‘burning mouth’ chapter, trust my ‘intuition’ and with good intention, but lazily, hand out a prescription more in hope than expectation? And why did it never occur to me to support the patient in finding a clinical trial aimed at answering the specific question at hand?
Testing Treatments may therefore challenge some of your assumptions, but it is a timely, inspiring read and perhaps a pointer to a future where scientific and humanistic values find their common cause within excellent clinical practice.