I鈥橵E been anonymously seeding Internet bulletin boards with Big Ideas for the
millennium. Most just disappear into cyberspace. However, one recently seems to
have fallen on fertile ground. Suddenly everyone鈥檚 talking about 鈥渆vidence-based
medicine鈥� as the biggest thing in healthcare since Hippocrates stubbed his toe
on the doorstep of his consulting room. The US, of course, leaps on any possible
cure for its trillion-dollar-a-year addiction to medical goodies. More
surprising is the enthusiasm of the National Health Service, which, by
international standards, already provides Britain with good value for money. But
in the latest round of NHS reforms, the government says that evidence-based
medicine will remove inequalities in treatment. It has even founded the National
Institute for Clinical Excellence, with the Blairite acronym NICE, to spread the
word.
Spoilsports point out that the idea of applying scientific discipline to
medicine is not entirely new. The British Medical Association鈥檚 secretary, Mac
Armstrong, says that Chinese doctors carried out a clinical trial of ginseng in
1061. My own modest research suggests that the concept of evidence-based
medicine was taken for granted in early 19th century England. The heroine of
Jane Austen鈥檚 final novel Sanditon, a satire on hypochondria, is
splendidly sceptical about the alleged toxicity of green tea:
鈥渀It sounds rather odd to be sure鈥欌�攁nswered Charlotte coolly鈥斺�檅ut
I dare say it would be proved to be the simplest thing in the world, by those
who have studied right sides and green tea scientifically and thoroughly
understand all the possibilities of their action on each other.'鈥� (Is this the
earliest use of the word 鈥渟cientifically鈥� in the modern sense? Postcards c/o the
Editor, please.)
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Despite this empirical heritage, there is reason to suspect that much of what
doctors do today is not based on science. One example of many: prescription
statistics suggest that diabetes is two and a half times as common in some parts
of Britain as in others. Almost certainly, this is not the case: it鈥檚 just that
some doctors treat the condition and some don鈥檛. So either a lot of sick people
are being untreated or a lot of healthy people are taking unnecessary drugs. Up
to now, we鈥檝e assumed that the two more or less balance out. But, in the new
evidence-based world, all this will change. It sounds like great
news鈥攗ntil you look at who鈥檚 driving the revolution. Not the doctors, not
even the drug companies. No, the real impetus comes from IT companies. Put
simply, evidence-based medicine is the latest wheeze for selling computers
to doctors.
According to Microsoft chairman Bill Gates, only 5 per cent of doctors in the
US use computers (the supposedly technophobic Brits do rather better, with 81
per cent of GPs doing some data-entry during consultations). Gates wants to
create 鈥渁 digital nervous system to turn the islands of healthcare into a single
continent of integrated care鈥�. The NHS, already a single continent, is promoting
a similar idea in a seven-year strategy to replace tatty old paper medical
records with electronic records available online. Prime minister Tony Blair says
that if you lived in Birmingham and were run over by a bus in Bradford, your
records would be instantly available to emergency teams. Doctors aren鈥檛
particularly impressed: apart from special alerts such as allergic reactions,
medical records aren鈥檛 much used in emergencies. Hence the focus on
evidence-based medicine, enabled through IT. The vision is of doctors carrying
hand-held computers on their rounds, tapping in data which will be instantly
available for research and audit. For the first time, we will really know which
treatments work and which don鈥檛.
I just wonder whether we鈥檙e ready for it. Of course medicine should be based
on evidence as far as possible鈥攁s should much else. But, in practice,
someone will always have to decide which evidence is admissible. Today, we
delegate these decisions to medical professionals, and any honest doctor will
admit to being swayed by habit, fashion, faith, politics and money. There鈥檚 no
guarantee that science will produce a better result鈥攐r even that it will
work out cheaper.
And when Gates and Co come up with futuristic visions, always remember that
they are among the people who brought us the millennium bug.