Archives for the month of: June, 2016

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I awoke on Friday morning in the North of England and have never felt more of a foreigner in my own country. Traumatised (I don’t think that’s too strong a word), I returned home to Scotland, and today I am feeling down as well as out. While this feeling has everything to do with the referendum, it has very little to do with the EU.

A decision has been made by people who didn’t understand what they were being asked, nor the consequences of their actions.  Those whom Nigel Farage described as ‘ordinary and decent’ won the day.  That does, of course, make those of us who did not put our cross in that particular box out of the ordinary and, at least in his eyes, anything but decent.  So, today I am simultaneously out of step with the majority of my country and have been branded indecent.

The unfortunate consequence of democracy is that sometimes you don’t get what you want.  And I’ve lived with that reality all my adult life — rarely being on the winning side. But this time, it’s different.  This time an enormously complex issue was reduced to a single inane question, which, if that was not bad enough, was then perverted by a gaggle of political also-rans, into a vote of no confidence in our current way of life.  Old crying men on TV are ecstatic that they have taken back their country, because they were told by politicians that it was all about ‘taking back control’.  An old woman dressed in a Union Flag dances as she rejoices that she has her ‘England back’ — not, interestingly, her Britain.  These voters’ discontents with their lives were whipped up into a frenzy of hatred and blame for the European project, when of course their all too real problems were nothing to do with Europe.

Immigration took centre stage in a display of extreme right-wing scapegoating that would have done the brownshirts justice.  When you’re poor, disadvantaged and disappointed, it is of course natural to want someone to blame — someone or something to punish.  And it was an act of retribution that we witnessed in the UK on referendum day.  Votes were cast to leave the EU by people who did not even know what the EU was, but they did so because they were promised greener grass on the other side of Brexit.  There are many layers of tragedy in this referendum, not least of all that these voters will in large part be the people who will pay most dearly for the decision.  The referendum was in effect an election for new management of the country, and that management will be right-wing and Britain will be smaller and much less significant than it has ever been in its history.

Today, there is less reason to think Britain is Great any more and we have awoken to find ourselves living in a Kingdom anything but United.  Scotland will seek independence and will achieve it; Northern Ireland will likely go backwards and London will see itself as ever more out of sync with the rest of England.

Feelings are undoubtedly running high at the moment and I am tempted to write things I may regret about the political leaders or would-be leaders who lied and manipulated the population for their own professional ends.  But, I won’t.  Time will reveal their deceptions for what they were and better commentators that I will highlight the poverty, job losses, factory closures, loss of trade and the educational impoverishment that will ensue.

For the moment, all that is left is to reflect on loss.  The loss of partnership, of respect, of our status as a civilised, hospitable nation.  And, when the dust has settled, the discovery that what we have really forfeited is a little bit of our humanity.

© Allan Gaw 2016



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We are constantly reminded of the importance of practising evidence-based medicine, and rightly so, for what is the alternative? But, in order to practise the best medicine, we need the best evidence — and we need to understand it. The latest evidence in the medical sciences is presented as a weekly diet of journal articles in an ever-increasing number of journals. This scientific literature presents the practitioner with two challenges. First there is the volume and then there is the quality.

We have to learn to read efficiently and selectively if we are ever to keep up, but we must also hone our critical faculties and, like all good scientists, take nothing at face value. How then should we read a paper critically?

All scientific papers set out to answer questions. When tackling a paper, your first task is to identify exactly what the authors have set out to do and why. Next, you should find out how they tried to answer their question. In other words, what sort of experiment did they perform. Depending on the topic you are reading about, this might be an experiment done in test-tubes on a laboratory bench, a study in mice or rats, or perhaps a clinical trial. Whatever was done, you should now be asking yourself if the approach was appropriate to the research question. For example, while an animal study might provide invaluable pre-clinical evidence for the effectiveness of a new treatment, it is never going to provide the sole evidence to support the use of a novel drug in patients.

The design of the study is crucial to its usefulness. The size of the study and its duration will affect how you view it, and what about the study participants — do you recognise them? Are they the same patients you see in terms of age, comorbidity and concomitant therapies? Or are they a cherry-picked group that does not mirror the population you are used to? If so, you may question how generalisable the study findings are to your practice.

Another key consideration in study design is whether the experiment is controlled. If not, the results, whatever they may be, are meaningless. If there is no control group, we cannot ascribe any change or treatment effect we might have observed to the intervention under study — what we have observed might simply be background noise.

In the paper, the authors will present their findings and from these draw conclusions, but are the conclusions plausible? If a paper reported that smoking does in fact increase your life expectancy, you should pause. Given everything that we already know about this lifestyle risk factor, such a finding would be hard to swallow. Similarly, if the authors of a relatively small, short study claimed that the drug they had studied should now be prescribed to everyone over the age of 35, you should be sceptical . Extraordinary claims require extraordinary levels of evidence. And, while consistency between multiple lines of evidence will make the conclusions more credible, disagreement should make us stop and think.

A study may be well designed and executed, and the data credible but the evidence may not support the authors’ conclusions. There may be an extrapolation that requires you to take little more than a leap of faith. There may also be simply other explanations of the data. For example, mere associations are often presented as cause and effect, when it is rarely that simple.

Which brings us to our next point — overall, just how good is the evidence? Publication does not alone mean that the evidence is of high quality. The better the journal and the higher its impact factor, the more likely the paper has been subjected to rigorous peer review. This means that poorly designed and underpowered studies should have been filtered out during the review process, but sometimes poor studies slip through the net, even of the better journals. When it comes to lower tiered journals their nets have bigger holes and you might have to work a bit harder to evaluate the quality of the evidence, for nothing can be taken for granted.

In summary, there are seven questions you should ask of any clinical research paper:

  1. What is the research question?
  2. How did they answer it?
  3. Was their approach appropriate?
  4. Was the study controlled?
  5. Do you recognise the study population as your patients?
  6. Is the answer plausible?
  7. Does the evidence support the conclusion?

To answer these you will have to focus on different parts of the paper and you will also have to do some thinking. The study may be published, but that doesn’t necessarily mean it’s valid or useful, especially to you and your practice. Critical evaluation is about gathering the facts, putting them in context, reflecting upon them and making decisions — decisions that will ultimately guide clinical practice.


© Allan Gaw 2016


A version of this article was originally published in the MDDUS publication GPst


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