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David Sackett: The Art of Fact-Sensitive Medicine



Professor Emeritus David Sackett

Professor Emeritus David Sackett

As recently pointed out in an article by Andy Borowitz in The New Yorker, we live in times where it seems that an increasing proportion of people living in the Western world (and not just there) appear to be “fact resistant”.  Indeed, an increasing number of people now appear completely unreceptive (even antagonistic) to actual scientific evidence, in favour of pseudoscience and magical belief systems reminiscent of witch craft and snake oil.

It is thus particularly sad, that we have to lament the loss of Dr. David Sackett, widely known as the “father of evidence-based medicine”.

While I never had the honour of meeting him personally (as his time at McMaster University preceded mine by almost a decade), no one in medical practice today can begin to fathom his many contributions to modern medicine, particularly in his insistence that clinical practice be informed by well-conduted randomised controlled trial (RCT) – the highest level of “evidence” for or against a given treatment or procedure.

Although not everything can be tested within the rigorous framework of an RCT, many questions can be and, whenever available, it is this evidence that practice decisions should be based on.

Indeed, one cannot even begin to list the questions that have been addressed through RCTs and have thus changed medical practice since I graduated from medical school.

While Sackett may have hoped that one day, all clinical decisions will be based on “evidence” (or scientific fact), I am less optimistic.

Much of what we do in medicine will never be formally tested in a clinical trial, not just because these are getting harder and harder to conduct (for regulatory and other reasons that I won’t delve into here) but also because formal clinical trials seldom fully reflect what goes on in actual practice with individual patients.

Nevertheless, his emphasis on the process and practice of “critical appraisal” in day-to-day medical care has led the way to a generation of physicians, who strive to always apply what we can know while being aware of what we don’t.

Here is a link to Dr. Sackett’s last interview – a lengthy, but worthwhile read.

@DrSharma
Edmonton, AB

 

 

2 Comments

  1. I think Sackett would be appalled to find someone conflating facts and evidence. Sackett’s contribution was to conceive formal systematic reviews of all the available medical literature with a view to separating wheat from chaff. Stressing transparency and highlighting potential sources of bias was key. Establishing a hierarchy of evidence was not the be-all and end-all. RCTs are science in the same way that economic studies are science — they’re not, but they’re the best we’ve got. Economists will acknowledge this, grudgingly. Doctors seem unable to do so.

    Sackett recognized that the medical ‘facts’ will change as the evidence changes. His contribution was to conceive and formalize a process to evaluate what’s out there. Conceptually it’s closer to MBA school ‘science of management’ or formal systems analysis than to the hard science of, say, physics or chemistry.

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    • I agree that “facts” and “evidence” are not the same – I used the term more in the sense that, “fact is that several large RCTs show that lowering blood pressure reduces risk for strokes”, rather than “fact is that lowering blood pressure prevents strokes”. Similarly, “fact is that there is no good evidence to support MRI immaging as routine work up for back pain”, rather than “fact is that routine imaging of backs for back pain is useless”.

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