3. Finding Good Medical Advice and Evidence-based Medicine

Finding medical advice that is good, reliable and evidence-based is not always easy. Here we examine what to look for reliable medical advice and what to reject.
This part is divided into the following sections:

If you wish to go directly to one of these topics, click on the blue underlined title above.

Reliable Medical Advice

Perhaps there has been another suggestion that mobile phones cause brain cancer and you wonder if you should let your children use them.

Perhaps Christmas and New Year have passed with an adverse effect on the waistline and you wonder which diet to try.

Perhaps someone is trying to sell you a herbal remedy or advocating acupuncture or homeopathy and you wonder if they are any good. What should you do? If it is personal recommendation, remember that just because it apparently worked for someone else, this does not mean that it will work for you. You need to research it.

You could start with the newspaper article if that is where it started.

  • What does it say?
  • Is there someone authoritative, such as NICE, who says that this is important new information and must be heeded or are the true experts rather more non-committal about it.
  • If someone other than the author thinks that it is important who is that person? Are they from a pressure group? That is not always obvious. 
  • Look at who wrote the article. It may have been the science or medical correspondent but it may also have been changed by the editor. Shock! Horror! Scandal! sells newspapers. A balanced assessment does not. It may have been written by a journalist who does not understand science but he does understand the selling power of sensation.
  • It may be a “celebrity endorsement”. Celebrities often get paid to endorse products and they usually fail to declare this. Even if it is a genuine, personal endorsement, celebrities are experts only in how to achieve celebrity status. Most of them are air-heads. They may have had experience of one personal case, but that does not make them an expert.
  • Where did you read it? According to the Daily Express, over the years, there can be few substances that do not either cause cancer or cure it. The Daily Mail has been convinced for years that there is something seriously wrong with the MMR vaccine despite a complete absence of evidence. Even The Times used to refer to GM produce as “Frankenstein foods” although in recent years it has taken a more rational line. With global warming everyone seems eager to report the latest prophecy of doom whilst remaining disinterested in more modest calculations or even the benefits of global warming.

As shown in the book 1Earth News by Nick Davies Flat Earth News,) there is a great deal of pressure on journalists to get a story out quickly without properly checking the facts and the source whilst sensationalism is preferred to a balanced appraisal. However, even the most biased and sensationalist newspaper is pristine compared with the world of blogging. There is even more pressure of time as income is related to the number of visitors to a site and hence advertising revenue. Sensationalism is far more attractive than reason and there is no penalty for promoting even the most blatant lie.2Trust Me. I’M Lying. Ryan Holiday

Fake news is not always obvious

After newspapers and magazines, television deserves a mention. For several years the BBC and ITV news insisted on referring to “the controversial MMR vaccine”, long after it had ceased to be controversial for any rational person. They like sensation and are reluctant to let it go. Medical topics are quite frequent on television programmes and they may be divided into drama and documentary or information programmes. Programmes such as “Casualty”, “Holby City” and “Silent Witness” have medical advisors and they often cover pertinent topics but it is important to remember that they are dramas and not real life. If they raise a topic that interests you, look further. These programmes are for entertainment rather than information.

Dr Michael Mosley

The other sort of programme is an information programme and they are often led by Dr Michael Mosley or Dr Xand Van Tulliken, with or without his identical twin brother Chris who is also a doctor. They explore some interesting topics and often get the opinions of true experts, rather than eccentrics. They often do experiments within the programme and these can show some of the basics principles of medical research as discussed in detail in Randomised Controlled Trials. By and large these programmes are good but I have two problems with their trials. The first is that, ideally, a subject should not know which treatment or intervention group he is in. However, as many of the interventions involve diet, exercise of the like, it is not really possible for the subject to be “blind” and unaware of their group. The bigger problem which as also covered far more fully in the other chapter is the size of the groups in their experiments. They rarely have more than a dozen in a group, but as we shall see, somewhere in excess of 100 may be required to make the trial valid. Hence, be careful of the results, especially if they are unexpected.

Xand and Chris Van Tulliken are identical twins

Xand and Chris Van Tulliken had a series called “The Twinstitute” in which they recruited identical twins for experiments. Identical twins are very interesting, having identical genes and being very similar in many ways. Hence it is possible to get away with fewer subjects. However, they often had just one of each pair of twins with one in each group or they may have two pairs, one male and one female. Even for identical twins with identical DNA, this number is far too small.

Where to Look for Good Medical Advice

Newspapers may raise interest in a story, but they are usually unhelpful to decide how important and valid it is. Articles in magazines or newspaper supplements are usually no better. They may not be quite as bad as the newspapers for sensationalism, but they are usually very weak on an evidence-based, balanced appraisal and often written by someone with an agenda. They may even be a sponsored article. One thing to ask is if it gives the arguments for and against the case or does it show just one side? There are always two sides to any story.

The NHS logo is a symbol of quality

If this is a recent matter with new evidence then books are likely to be out of date. In the present day, the place to turn to for information is undoubtedly the Internet. There is a vast amount of information out there but quantity is no guarantee of quality. If you put in a search for “was the holocaust real?” you will get many sites that tell you that it was all a fabrication. Do not believe everything you read.

Where can you look for honest, unbiased and reliable advice?

Nevertheless, the best start is probably an Internet search engine. There are several available and I am reluctant to favour any although I tend to avoid Google because of its excessive power in the industry. I use Bing but it may be not much better. Bing is run by Microsoft and with both Google and Microsoft, I object to how little tax they pay on astronomical earnings. However, we need an efficient search engine and that means going to the big boys.

Seeing the Wood for the Trees

Do not confuse quantity with quality of information on the Internet

The problem is information overload. Suppose that someone had recommended that I should try reflexology for my problem and I want to know more. I did a Google search for “reflexology” and it returned 3,200,000 items. I did not wade through all that although many are duplicates. You can modify your search. I tried “reflexology evidence” and this brought it down to 688,000, still an impossible number. “Reflexology trials” increased the number to 804,000 but “reflexology reviews” reduced it to 376,000. If my problem is irritable bowel syndrome, I could search for “reflexology for irritable bowel syndrome, controlled trials”. However, even that produced 1,690,000 results. This has more than doubled the number found by “Reflexology trials”. It must have searched for either/ or. I repeated with just “reflexology for irritable bowel syndrome” and got a mere 151,000 results. It is good to look at more than one resource to get a fuller picture but this is still unmanageable.

Breakthroughs are not sudden flashes but the result of years of diligent work and appraisal

Science does not progress with sudden leaps but an accumulation of much evidence over the years. A single clinical trial or other study rarely has a dramatic effect on the balance of knowledge and hence perceived wisdom. Not all evidence is good. Sometimes genuine and well conducted research may be misleading. You could try to find every single scientific paper on the subject and try to form your own opinion. Not only is this very time consuming but also very difficult. Interpreting the literature and the validity of a paper is a skilled task and it is better to leave this for the experts. Furthermore, if an expert has taken the time and skill to do this, why try to re-invent the wheel? However, before we look at reviews and systematic reviews, both here and in a later section, let us look at where to get a good and reliable source of information.

A search presents a very large number of websites. Many of them will be duplicated within the search, often several times. By and large, the ones at the beginning of the list will be more relevant than those later on. As you go down the list look at the titles at the top of each entry and the name of the website. To go down my last search of “controlled trials of reflexology for irritable bowel syndrome” I find that many of the titles show that they are related to irritable bowel syndrome (IBS) but they do not relate to reflexology. They included trials of probiotics and turmeric.

As well as looking at the title it is very important to check the address or URL of the site. URL means Uniform Resource Locator. It is the global address of documents and other resources on the World Wide Web (www). This gives an indication of the nature of the site. It is not quite as easy as distinguishing www.sanity.org against www.looniesrus.com (do not try the link as they are not a real websites) but it often gives an indication of the nature of the resource. The country of origin may be given by the last two letters, so that uk is United Kingdom, fr is France, de is Germany and au is Australia. American sites do not usually have a country suffix but many without a suffix are not American. This is especially true of those that end in com. The ending eu is sometimes seen for European Union. One other suffix of note is int which means international. The classical example here is http://www.who.int/en which is the World Health Organisation. The / (pronounced forward slash) in a web address directs to part of the site. In this case en means that it is the section written in English.

Many of the URLs given here are at the end of a sentence and so are followed by a full stop. Do not include that full stop in the URL or you may fail to find it. The URLs given often start with http:// before the www. The http:// means hypertext transfer protocol and can be omitted when typing it into the box for the web address as Internet Explorer will add it automatically. Not all references start with www and so do not add it is not there. In the latest versions of Windows the www is often added automatically if it is omitted but needed.

Some Good and Reliable Sites

For a health-related issue there may be sites ending with “nhs.uk” in the URL. This means that they are from the NHS and they give a reliable and authoritative summary of current wisdom and knowledge and are kept up to date. They are not government propaganda but summaries written by people who know the subject. You can just put in https://www.nhs.uk/ and go to “Health A-Z” or “Medicine A-Z”. Alternatively, you can use the search box at the top of the page. If you just type in nhs.uk, the rest of the URL will be completed for you. The same applies to gov.uk.

Most or all government departments are within the domain of http://www.gov.uk. I believe that around 230 different government website were amalgamated on to this one site. The Department of Health is at https://www.gov.uk/government/organisations/department-of-health-and-social-care This will give you all sorts of information about health from your local GPs, dentists or pharmacists to advice on health issues.

If you want to know about medical conditions and driving, try https://www.gov.uk/driving-medical-conditions For almost anything related to government, go to http://www.gov.uk where there are a number of options to follow or search for your topic in the box “Search GOV.UK”.

The articles on NHS sites which give advice are usually peer reviewed. This means that before publication the article has been passed to at least two independent assessors who are experts in the field for their opinion. This also happens with research papers for scientific journals of repute. Not all are of repute, especially along the fringes of medicine and alternative medicine. Respected journals such as The BMJ and The Lancet will always use peer review. BMJ was the British Medical Journal and is a highly respected source.

The ending ac.uk means that it comes from an academic source in the UK, usually a university. These are usually good resources. However, some may represent the views of the author rather than the department and some academics are mavericks. It may say, “The views expressed on this website are those of the author and do not necessarily reflect the policy of the department.” American academic sites usually end in edu. The site may indicate exactly which academic department it represents but you may need to do a search on part of the address. Take https://www.rcplondon.ac.uk for example. A search of “rcplondon” shows that it is not a university but the Royal College of Physicians of London. The letters org means organisation. The URL https://www.rcgp.org.uk is the Royal College of General Practitioners. If you are directed to a site of one of the Royal Colleges this should be seen as a mark of quality for the content. Org means organisation. Organisations may include patient groups such as http://www.bhf.org.uk which is the British Heart Foundation and and http://www.diabetes.org.uk is Diabetes UK, formerly the British Diabetic Association. Whilst these organisations are patient advocates they are still realistic. They tend to have medical advisers of great renown and the advice and information that they give is almost always sound. Note my reservation of “almost always sound” as not all are uniformly good.

Many of these websites have changed in recent years, so if you fail to reach them, put an appropriate term in a search engine. It may be helpful a to add “UK” to get a British site.

PubMed gives access to many millions of papers

Some URLs may start with https://www.ncbi.nlm.nih.gov/pubmed and this is an interesting and useful resource. The National Center for Biotechnology Information is based in Washington DC and it is a resource for a vast number of scientific papers, especially from medical journals. I shall discuss this site a little later as it is so important.

Wikipedia should be treated with caution

Wikipedia is an interesting resource. To quote their own website, “Wikipedia is written collaboratively by largely anonymous Internet volunteers who write without pay. Anyone with Internet access can write and make changes to Wikipedia articles (except in certain cases where editing is restricted to prevent disruption or vandalism). Users can contribute anonymously, under a pseudonym, or with their real identity, if they choose.” This is the problem. It is not peer reviewed and so the quality of the content is not assured. Nowadays most university students have to write essays that must quote the source of their information and tutors do not accept Wikipedia as a source. If you use it, use it with care and scepticism. Some people change Wikipedia entries as a joke.

You will see that most of my references are academic sites. In the history section the biographies of Nobel Laureates comes from the Nobel Organisation site. The Science Museum is another excellent site.

Websites to sell a product will not give a balanced view

Sometimes it may be apparent that the website belongs to an organisation with a commercial interest in the topic. This includes those who are promoting alternative medicine. They will be excessively enthusiastic about results that can be achieved and the evidence base of their work. If you want to find the value of nutritional supplements you will not be surprised to find that companies that sell them are enthusiastic about them. They are not likely to confess that with a good balanced diet they are totally unnecessary. The website may be run by a pressure group. You could compare the views of two opposing pressure groups to compare the two sides of the story. Alternatively, you may simpler seek a less biased source. A site with “catholic” in the name will conform to the teachings of the Roman Catholic Church. It may be obvious from the way that information is presented that this is a source with a strong pre-conceived opinion that is not going to give a balanced view.

Those that are trying to sell something may offer testimonials about their product and they are common in any sales literature. Testimonials are a complete and utter waste of time. They may be genuine. They may not. You will certainly not be offered a list of complaints about the product. You need a balanced opinion.

It is said that 1 in 4 of people who search the Internet for health related issues do not take any notice of the source of the site and information. This is a great mistake. By and large, it is a good idea to keep away from sites where the accuracy and balance of the information is dubious. So where is a good place to look?

So far we have looked at sifting the vast number of sites turned up by a search engine. Now we can look for more specific sites. Perhaps you have recently been diagnosed with a disease or someone close to you has and you wish to know more about it. You could look for the relevant patient support group. Use a search engine to put in the name of the disease followed by “patient support group”. Add “UK” or you may be directed to sites in the USA and elsewhere. The foreign sites may be interesting, but the British sites will be most relevant in terms of help and support that is available through the NHS and other agencies. Furthermore, you may wish to contact or join the relevant group. The URLs for the British Heart Foundation and Diabetes UK have already been given.

If an infectious disease interests you, such as measles or food poisoning, the best site is Public Health England, or presumably Wales, Scotland or Northern Ireland if you are there. The web address for England is
https://www.gov.uk/government/organisations/public-health-england

For Wales it is https://phw.nhs.wales/

For Scotland it is https://www.publichealthscotland.scot/

For Northern Ireland it is https://www.publichealth.hscni.net/

The exact URL often changes and so I might not be up to date, although I review this site regularly. If the link fails, put what you want in a search engine.

If there has recently been an outbreak of food poisoning from E coli O157, for example, it will describe the symptoms and explain such complications as the haemolytic-uraemic syndrome. They may give an update including possibly a link to the Foreign Office if there is relevant advice about travel abroad. There is also a link to the Health and Safety Executive for advice about preventing E coli outbreaks on farms and in children who visit farms or animal areas. It is written clearly for the general public and avoids technical words. The Health Protection Agency (HPA) used to be the agency but now it is superseded by Public Health England (PHE) or the agency for the related region of the UK.

An excellent source before travel abroad is the National Travel and Health Network and Centre (NaTHNaC) at http://www.nathnac.org. This is probably the best for seeing which immunisations you need for foreign travel. It is good if there is a current problem such as typhoid or cholera in the world and you are wondering whether to travel or what precautions to take. For infectious diseases that doctors have to report (notifiable diseases) such as measles or meningitis it will give reported numbers per month. It is a useful resource for HIV and sexually transmitted diseases. The American equivalent is the Centers for Disease Control and Prevention, found at http://www.cdc.gov . This is also very good but is aimed at the USA rather than the UK.

National Radiological Protection Board (NRPB) covers all issued related to radiation. If it is a radiation issue that concerns you, try https://www.gov.uk/government/collections/national-radiological-protection-board-nrpb-report-series/ and then enter your search topic on the site. If the matter is radiation at work then the Health and Safety Executive (HSE) is found at https://www.hse.gov.uk/ . This is gov.uk because it is a statutory body with the power to prosecute if necessary. It gives a great deal of helpful advice. Its ethos is to help industry rather than heavy-handed enforcement. Prosecution is a last resort but one which it will use. If you run a small business you may wish to know if your company is complying with the relevant legislation.

What to Reject

Having examined where to look for sound medical advice, the next section must be where not to look. Unfortunately, I am unable to offer any simple, clear and effective advice that will help to exclude all fake news and false advice but do not be impressed by celebrity endorsement.

Can you sift the rubbish and find the gems?

The Internet is the source of much good advice but also the source of many lies and disinformation. Look at the site to see who owns or runs it. Is it information or an advertisement? If it claims to be some new breakthrough or a treatment with loads of scientific evidence to support it, look elsewhere to see if you can find this to be substantiated. Try a site such as PatientUK or do a PubMed search. Are there really thousands of papers to support it?

It is important not to be gullible about fake news. How do you recognise it? If a story seems too outrageous to be true, perhaps it is not true but true stories can also be incredible. Where did you see it? Was it a mainstream news site of a webpage you had never heard of. Was it a re-tweet? Can you find the story confirmed on credible sites such as the BBC website or a reliable newspaper. Fake news is often emotive as it is designed to get a reaction and to make you angry. You can also put the assertion in a search engine with “hoax” and see what comes up. You can also use the British website https://fullfact.org/.

Fake new can spread at a phenomenal speed. Suppose that a group of 20 on Whatsapp gets a false story and relay it to another 20 people who all do the same. If this happens 5 times, it reaches more than 3.2 million people.

In March 2019, The Times ran an article headed, 3 Google cashes in on dementia pills that give patients false hope, accusing Google of profiting from advertising revenue from fraudulent claims that tried to sell useless remedies for dementia. If a person or someone near and dear is diagnosed with dementia, it is devastating and naturally, people will look for solutions. The fact that scientific medicine has little to offer for this appalling condition helps to make the diagnosis more traumatic than cancer or heart disease. There has been no new drug for dementia since the turn of the millennium, but many failures.

Vendors will not undersell their product

This makes people very vulnerable to the snake-oil salesmen as they are desperate. The Times said that, “Google sold advertising to retailers of brain supplements under online searches for terms such as Alzheimer’s pills and dementia supplements. The advertisements were approved by Google under policies that are supposed to keep adverts safe and appropriate for everyone. The market for “brain supplements” is estimated to be worth £2.4 billion each year although they are totally useless. The retailers paid Google between £1 and £3 per click to reach people.

The Times said that searches such as “Alzheimer’s supplements” brought up advertisements for products including a supplement costing £38-a-month that claims to promote memory, featuring “clinically studied whole-food ingredients” such as organic avocado. Another supplement claims to promote normal cognitive function through a formula based on assessment of “over 10,000 scientific studies”. Disclaimers on the products say that they are not intended to treat or prevent any disease. Then why should anyone buy them? Presumably, that is the small print that buyers are not expected to read.

Google also advertised books that claim to tell readers how to “prevent and reverse” the cognitive decline of dementia and “reverse Alzheimer’s disease naturally”. Once again, we have that wonderful word “naturally”. Books are not more reliable than the Internet and must be subjected to the same scrutiny.

A Greek proverb but often attributed to Thomas Moore

There is no cure for dementia, but there is licensed medication that can reduce the symptoms and experts believe that lifestyle changes may reduce the risk of dementia. American neurologists say that patients or families often ask about dietary supplements, marketed for brain health. There is no evidence of any benefit. Companies making false medical claims are in breach of advertising rules, but many do it. Google said: “We have strict policies that govern the kinds of ads we allow on our platform, and ads for products that offer ‘miracle cures’ are a violation of those policies. When we find ads that violate our policies, we remove them.” A month before the article, the US Food and Drug Administration warned 17 companies that it said were illegally selling products claiming to prevent or cure Alzheimer’s disease.

While some products claim scientific backing and may even link to studies to prove their efficacy, they may point to trials that appear to show success but failed to reach statistical significance or they point to results in early-stage animal trials that have no relevance to humans. They often cite papers from journals that do not have a proper peer-review system. Sometimes the author just pays and gets published.

Beware of anything called “natural”

I put in a search for “avocados for Alzheimer’s” and there were a number of sites extolling their virtues to prevent rather than treat dementia, so I went to PubMed and put in “avocados and dementia”. It returned three papers, none of which was relevant. My conclusion is that there is no scientific evidence that avocados prevent dementia.

The Times said that Google has stopped selling adverts under these terms related to dementia after its investigation. An editorial to support the article was headed4The Times view on Google’s promotion of dementia ‘therapies’: More Lies Online. The subtitle was “Mendacious and exploitative advertising is shielded by search giants.”

As Google claimed to have removed such advertisements, I tried a Google search a few days later for “cure dementia”. I was offered “cure dementia naturally”, “cure dementia with diet”, “cure dementia with homeopathy” and “cure dementia with coconut oil”. There was no shortage of sites offering bogus advice. Several were for an American organisation called “the Women’s Alzheimer’s Movement” which is obviously a sexist organisation as there is no significant difference in how the disease affects women and men. According to another site, “The most effective home remedies for dementia include the use of ginseng, salvia, turmeric, ginkgo, fish oil, bananas, cinnamon extract, vitamin B12, coconut oil, club moss, berries, almonds, pumpkin, leafy greens, beans, and kale.” There is no evidence for any of this.

Would you buy medicine from this man if he was online?

I then tried a search on Bing for MMR vaccine and when one of the options was MMR and autism, I clicked on this as a common concern. Most of the sites I was offered, including the National Autistic Society, were quite clear that there was no link between the MMR vaccine and autism. However, I did find one from The Daily Mail Australia, headed “EXCLUSIVE ‘I don’t care what the outside thinks of me’: Kristin Cavallari has ‘no regrets’ years after she linked childhood vaccines to autism in controversial anti-vaxxer interview”. If you want to know about science and you seek the advice of not just a celebrity but a reality TV star, you have it coming. I was impressed with the Bing list as it seemed to lead with rebuttals of the MMR and autism lie rather than fantasy and conspiracy theories. I did the same search on Google and received similar results.

In late 2019, The Times was highly critical of Google for permitting advertisements for substances that were not just ineffective, but dangerous too.5Google pushes quack cancer cure Miracle Mineral Solution One substance was Miracle Mineral Solution (MMS), which contains chlorine dioxide used in water purification and bleach. It has been advertised to cure cancer, autism and AIDS. Those three claims together should immediately spark scepticism and if it does work, why is it not available through conventional channels? Google displayed one advert for MMS in the form of chlorine dioxide water purification drops, which told users to add them to a bath “for a total healing detox”. The instructions added: “Basically, it will heal anything.” People with cancer can be desperate when told that they have a potentially fatal disease, but they need scientific medicine, not to be fleeced by charlatans.

Of course, the Internet is not the only source of garbage. In that interview in The Daily Mail Australia, the airhead said that she had read many books about the MMR vaccine and autism. No doubt she had chosen only to read the books that coincide with her preconceptions. You must remember that books are published to sell, not because they are necessarily true or reliable. Look at the number of celebrity diet books available. If a book is in your local library, that does not offer any sign of quality. Many of the books in the medical section of my local library should be in the fantasy fiction section. I have tried moving them over, but the librarians move them back. Look at who wrote books. Check the author. Does it seem to be someone with a genuine expertise or a self-appointed expert. See how amazing the claims are. The more amazing, the less likely they are to be true.

Keep your bull-shit detector on at all times

Do not be reassured by the website which led you to the advertisement. For example, you may have been on the Alzheimer’s Society website and followed an advertisement to something that the society would definitely disapprove, such as a quack remedy to cure dementia. Most websites that accept advertisement have no control over the advertisements that may appear on their site. Advertisements give revenue but they may be regretted.

Often it is just a matter of trying to get a “feel” for a website or book. Have your bull-shit alarm set on sensitive. Do they represent an antivax group or a health service provider? Is there an obvious vested interest such as selling food? If they insist that the wonder food must be organic, their claims are usually groundless. Seeking evidence is like the quest for truth and sifting out fake news. It is not easy. Some simple questions may be:

  • Does it seem reasonable?
  • What is the source of this information?
  • Can I find it authenticated elsewhere? This does not include a re-tweet of the same story.

Beware of personal bias. Is it very easy to convince anyone of something which they want to believe and very difficult to convince them of something they do not want to believe. That applies to everyone; even me and you.

NICE

The National Institute for Clinical Excellence is now called the National Institute for Health and Clinical Excellence but it retains the acronym NICE. Its website is found at http://www.nice.org.uk . They are org.uk rather than nhs.uk as they are separate from the NHS but essential to it. An outline of what they do is found if you click on “about us” on the homepage. NICE is aimed primarily at healthcare professionals but it also produces advice for patients in language that a lay person will understand. According to its website, NICE guidance is :

  • Designed to promote good health and prevent ill health
  • Produced by the people affected by our work, including health and social care professionals, patients and the public
  • Based on the best evidence
  • Transparent in its development, consistent, reliable and based on a rigorous development process
  • Good value for money, weighing up the cost and benefits of treatments
  • Internationally recognised for its excellence

NICE is best known for its guidance which is not just for doctors but often written with patients and public in mind. The NICE guidance that is most often brought to the public’s attention is where they do an appraisal of new technologies that includes drugs for diseases such as cancer or Alzheimer’s disease. They may decide that the benefits offered by a drug do not merit the cost involved. This is usually met with an outcry in the media, orchestrated by pressure groups and backed by the relevant pharmaceutical company, along the lines of “cost cutting before cancer” but NICE explains how it makes its decisions.

If a drug adds a little more life, but perhaps still of poor quality, to a person with advanced cancer but it costs a great deal of money, we have to ask if that is money well spent. Understanding this will be explained in a later section called Basic Maths in Medical Research and Decision Making. The NHS is funded by taxation and has a finite budget so that what is spent in one field is not available to be spent elsewhere. Setting priorities and getting the best value will always meet opposition from conflicting interests. The critical article in the newspaper may well be almost copy and paste from the information sent from a PR source in the pharmaceutical industry.

Weighing the evidence against the gold-standard

There are a number of resources that are available on the Internet that are really aimed at doctors or other professionals but which may be of interest. There is a risk that they may be misunderstood. What is more likely is failure to understand some technical words or jargon. A medical dictionary may help or just put that word or phrase into a search engine to find what it means. There is plenty of information for the resourceful. One such source that is designed for general practice is Clinical Knowledge Summaries (CKS), formerly known as Prodigy. It has been taken over by NICE and is found at https://cks.nice.org.uk . Note that there is no www. Its URL shows that it is linked to NICE. Nowadays doctors have plenty of access to evidence based advice but it is not usually directly available to the public.

One exception is the Webmentor Library produced by EMIS. EMIS is an acronym for Egton Medical Information System and it is the most commonly used GP computer system in the UK. It was used by 55% of practices in England but it has become less popular more recently. Usually doctors would get access to such information via their practice computers, but the general public can gain access via https://patient.info/ . Near the top of the page, click on “professional reference”. In the “search patient plus” box enter your topic such as “angina” and a number of resources appear. If you click on one of the topics you will find an excellent article but it is written by GPs for GPs and not for the public. These articles are regularly updated. They contain references that can be followed directly from the text. These articles are peer reviewed which means that they have been checked by at least two doctors with an interest in the subject before publication. It is also possible to get articles on the patient UK website that are written for lay people. The Patient UK website now seems to be run by EMIS and it offers a wide range of information and the quality of information seems rather better than it used to be.

Reviews and Systematic Reviews

You may possibly decide that you want to look at the original papers in scientific journals on which evidence was based. Here I refer back to The National Center for Biotechnology Information based in Washington DC as mentioned a little earlier in this chapter. The US National Library of Medicine National Institutes for Health runs a service called PubMed that may be accessed at http://www.ncbi.nlm.nih.gov/pubmed. It includes more than 16 million citations from various medical journals. The site gives some help about how to use the resource. To return to irritable bowel syndrome, I put in a search there for “IBS systematic reviews” and it gave 90 resources. The nature of systematic reviews will be explained later. This is much more manageable than hundreds of thousands or millions. I then tried “reflexology for IBS, systematic reviews” and it returned two. I can now see the wood for the trees.

The systematic review is the ultimate assessment of the evidence

For most of the papers that are listed on PubMed it is possible to get an abstract which is a condensed version of the research and the findings. Some papers, especially the older ones, may not have an abstract. Occasionally the full text is available free of charge, especially for important papers. More often, if you really want the full text, you may have to go to the publisher’s website and pay for access. On a number of occasions in this book you will find that the reference includes the words “full text” in square brackets. This will be used only when the full text is available without payment. However, whilst this is true at the time of writing it may not be so at the time of reading.

Scientific papers can be complex, turgid, badly written and involve complex statistics

Quite honestly, most people just read the abstract of a paper and never go any further. The whole paper, if available, may be long, tedious, turgid and mired in complicated statistics. If you want to read a little more than the abstract, then the conclusion and discussion may offer more information without inducing tedium and confusion. You may wish to refer to an original paper because it was an important landmark, perhaps a large and well conducted study or a topic that is rarely covered elsewhere. However, isolated papers can be misleading, even when they are well conducted research that is well reported. Not all research falls into this category. Therefore a summary or review paper may be preferable.

Many medical and other scientific journals have a number of leading articles or editorials at the beginning of each issue. They may relate to an important current issue such as another NHS reform or they may be about an important paper that appears in that issue. It was traditional for leading articles or editorials to be anonymous as they usually are in newspapers. However, they can be a rather biased view of the situation and the general consensus nowadays is that the authors should be named as the reader may recognise them as people with a specific view.

This is why reviews are rather better if they are available. The best type is called a systematic review. Doing a proper systematic review is very hard work. It should include the following tasks:

  • Identify all relevant published and unpublished evidence
  • Select studies or reports for inclusion
  • Assess the quality of each study or report
  • Synthesise the findings from individual studies or reports in an unbiased way
  • Interpret the findings and present a balanced and impartial summary of the findings with due consideration of any flaws in the evidence.

It is necessary to find all the relevant literature on the subject. As well as computer searches, manual searches must be done. Whereas editorials and ordinary reviews may be biased, systematic reviews are supposed to be neutral. They are regarded as the gold standard of condensing evidence. Unfortunately, not everything called a systematic review is of the required standard. In 2004 Professor Edzard Ernst from the Department of Complementary Medicine at Exeter University did a systematic review of systematic reviews for homeopathy. He was not impressed.

What is Evidence-based Medicine?

Evidence-based medicine was defined by David Sackett and others back in 1996 as, the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients.6Evidence based medicine: what it is and what it isn’t It is the practice of using scientific research and reviews to influence medical decision-making in medicine. It may be deciding which drug should be used to treat an illness based on its performance in medical trials. Using evidence based medicine aims to eliminate decision-making based on more traditional methods in favour of using solid scientific proof. The process of using tried and tested methods aims to improve the efficiency and effectiveness of patient care whilst also saving time and eliminating unnecessary costs.

When looking at reviews you may come across meta-analysis. As we shall see in the section on Randomised Controlled Trials, large trials are better than smaller ones. They are more likely to give reliable results. Basically, meta-analysis involves adding up the results of several trials as if to make one large one but this will be discussed more fully later.

When looking for systematic reviews, the most respected ones come from the Cochrane Collaboration. This is an international organisation that is fiercely independent. They ask reviewers from all around the world to produce systematic reviews. Being asked is a great honour. A meticulous piece of work is an obligation. The World Health Organization (WHO) awarded the Collaboration a seat on the World Health Assembly in January 2011, allowing it to provide input on WHO health resolutions. Their website is found at http://www.cochrane.org and there are a great many topics covered by systematic reviews that are updated every few years. If you can find the topic in a Cochrane systematic review you have your result.

From James Lind’s trial it took the Admiralty 40 years to implement a policy to eradicate scurvy from the Royal Navy. The work of Ignaz Semmelweis on cross infection on maternity wards was studiously ignored. Today we have excellent ways of assessing all available knowledge and disseminating advice based on best knowledge and practice. This applies not only to the NHS but throughout the world. There is no excuse for living in the Dark Ages any more.

Further Resources

  • Medical terms explained. Royal College of Obstetrics and Gynaecology
    https://www.rcog.org.uk/en/patients/medical-terms/
    A useful resource for the lay person but orientated to obstetrics and gynaecology rather than general medicine
  • Crombie I. The pocket guide to critical appraisal. London: BMJ Publishing, 1996.
    Designed for doctors. How to assess the validity of a paper.
  • Greenhalgh T. How to read a paper – the basis of evidence based medicine. London: BMJ Publishing, 1997.
    Also aimed at doctors. The things to look for in a paper
  • Bad Science. Ben Goldacre. Fourth Estate, London (Harper Collins Publishers). 4th Ed 2009.
    An excellent book that should be mandatory reading. It exposes a vast amount of rubbish that is promoted as science. This book will be mentioned at the end of a number of other chapters.
  • Flat Earth News. Nick Davies. Vintage Books London 2009.
    It lifts the lid on misrepresentation and lies in the press
  • Trust Me. I’M Lying. Ryan Holiday. 2012
    Confessions of a blogger, showing how devious tricks, innuendo and overt lies are used to sway public opinion and how the “blogosphere” is driven by the need to get clicks with no regard for truth.
  • The Centre for Evidence-based Medicine in Oxford. https://www.cebm.net//
    A good resource but aimed more for the professional audience

References

  1. Flat Earth News. Nick Davies. Vintage Books London 2009
  2. Trust Me. I’M Lying. Ryan Holiday (self-published). 2012
  3. Google cashes in on dementia pills that give patients false hope. The Times 25th March 2019.
    https://www.thetimes.co.uk/edition/news/google-cashes-in-on-dementia-pills-that-give-patients-false-hope-3gkqkll9v
  4. The Times view on Google’s promotion of dementia ‘therapies’: More Lies Online. Editorial
    https://www.thetimes.co.uk/article/the-times-view-on-google-s-promotion-of-dementia-therapies-more-lies-online-v2wn6qpss
  5. Google pushes quack cancer cure Miracle Mineral Solution. The Times 28 December 2019.
    https://www.thetimes.co.uk/edition/news/google-pushes-quack-cancer-cure-miracle-mineral-solution-jjjhhwg36
  6. Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson WS Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71 hhttp://www.dcscience.net/sackett-BMJ-1996.pdf

Site Index

This website is now completed, although I shall continue to do updates. The following list shows the sections or chapters. Just click on the topic in blue to go to that part of the site.

1 Introduction
2 A Very Brief History of Science And Medicine
Fundamentals of Medical Science
3 Finding Good Medical Advice and Evidence Based Medicine
4 Randomised Controlled Trials
5 Cohort or Longitudinal and Epidemiological Studies
6 Qualitative Research
7 Basic Maths in Medical Research and Decision Making
8 How Good is the Evidence?
9 Ethics in Practice and Research
Public Health Issues
10 Screening Programmes
11 Fake News and Vaccine Scares
12 Electronic Cigarettes (E-Cigarettes)
13 Motor Vehicle Emissions, Air Pollution and Health
COVID-19
14 COVID-19. What You Need to Know
15 Who is at Risk from COVID-19
16 What we Must Learn from the COVID-19 Pandemic
Nutrition
17 Basics of Nutrition
18 Exercise, Obesity and Diets for Weight Loss
19 Diets and Nutrition for Health and Fitness
20 Supplements
Complementary and Alternative Medicine
21 Introduction to Alternative Healthcare
22 Homeopathy
23 Acupuncture
24 Manipulation of the Spine
25 Reflexology
26 Herbal Remedies
27 Other Natural Products
28 Chelation Therapy
29 Hypnosis
30 Other Modalities of Complementary and Alternative Medicine
Some Controversial Diseases
31 Fibromyalgia
32 Chronic Fatigue Syndrome (CFS) or Myalgic Encephalitis (ME)
33 Systemic Candidiasis and Leaky Gut Syndrome
34 Mobile Phones, Masts, Wi-Fi and Electro-sensitivity
The Environment
35 Global Warming and Climate Change
36 Alternative Energy
Some Final Thoughts
37 Still Searching for the Age of Reason