How do you make doctors?
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How do you make doctors? book
A major reason for medicine’s role in driving the ‘what works’ agenda is that its ontology and epistemology are firmly rooted in the natural sciences, and the use of controlled experiments to test causal associations. In the 1970s, a highly regarded epidemiologist berated doctors for using ineffective or frankly harmful treatments (Cochrane, 1973). Cochrane urged doctors to find which treatments did and did not work by carrying out randomised controlled trials. The evidence-based medicine movement gained momentum slowly over the next two decades until two more or less coincident events. A clinical trial was published, showing that ‘clot-busting’ treatment (streptokinase) and aspirin could, together, save the lives of people after heart attacks (ISIS-2, 1988), and a statistical meta-analysis was also published, showing that evidence for the effectiveness of streptokinase had existed in fragmentary form for a long time but had simply not been assembled (Antman, Lau, Kupelnick, Mosteller and Chalmers, 1992). The inference was that conducting systematic reviews and meta-analyses was the answer to Cochrane’s criticism. An international collaboration, The Cochrane Collaboration, was therefore formed to promote the scholarship of evidence synthesis (Cochrane Collaboration, n.d.). Meanwhile, a group based in McMaster University, Canada, developed Evidence-Based Medicine (EBM) as a discipline that could bring such evidence to bear on clinical practice. Heuristics for appraising and applying evidence were developed and promoted (Sackett, Richardson, Rosenberg and Haynes, 1997) to support EBM. A central concept of EBM is the ‘evidence hierarchy’, which prioritises various research methodologies and evaluates the strength of evidence according to its level in the hierarchy. Statistical meta-analysis of randomised controlled trials is at the top of the hierarchy and any other methodology is considered inferior. EBM therefore aims to take uncertainty out of clinical practice by showing ‘what works’ and using methods that weight probabilities in favour of one course of action over another. This approach resonates with doctors, who have to demonstrate proficiency in science to enter medical education, and whose learning of medicine is dominated by the experimental paradigm of the natural sciences; it has also influenced medical education research and the processes involved in educating medical students.