When researchers stumble, clinicians fall and patients suffer
When researchers stumble, clinicians fall and patients suffer
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当研究人员跌倒时，临床医生也会跌倒，患者也会受苦
DOI：
10.5750/ejpch.v4i3.1192
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发表时间：
2016
期刊：
影响因子：
--
通讯作者：
L. Granan
中科院分区：
文献类型：
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作者：
L. Granan
如果你想养成一种习惯，重复你的行为。如果你想养成一个有益的习惯，那么在你重复之前，修改并反思你的行为及其含义。纵观慢性疼痛医学的实践现状，人们观察到一种重复的行为，一个不令人满意的病人结果和偶尔的反思实践，这并没有转化为改变临床实践。我并不是在暗示实践者所做的每件事都是完全错误的，只是说他们对于自己实际在做什么、什么时候应该做什么以及应该对谁做什么几乎一无所知。因此，让我们退后一步，评估2016年的研究告诉我们的一般医学科学，特别是疼痛医学（即长期疼痛状况）。Chalmers、Glasziou和Ioannidis都向我们表明，大多数发表的研究既不可靠，又与临床无关[1,2]。这本身就是一个很严重的问题，但事实更糟。几乎没有任何已发表的临床发现被复制，因此，对真正重要发现的证实通常是不存在的。到目前为止，我们知道我们的大多数临床知识都是错误的和未经证实的。此外，我们知道大多数临床医生不能正确地解释研究结果。因此，大多数临床医生将不断面临违反希波克拉底誓言的可能性。研究人员和临床医生的极其重要的工作提供了一些拯救，这些工作提醒我们，综合医学知识并将其作为（免费）可用的指导方针和建议提供的严格方法的重要性。其他科学受益者是研究人员，他们使用高端随机对照试验来测试在将信息转化为知识用于共同决策（以人为中心的医疗保健bb0的关键组成部分）时，哪种格式的概述指南信息对临床医生最有帮助。至于长期疼痛，我们知道慢性原发性疼痛（如腰痛、颈部疼痛、纤维肌痛）很可能是世界上最昂贵和致残的疾病。对于医学界来说，这种令人担忧的情况没有任何有效的治疗方法。事实上，到目前为止，在慢性疼痛医学领域，还没有一项独立研究小组能够复制的干预措施，其效应量既具有统计学意义，又能证明相对于安慰剂干预措施有临床相关的改善[7,8]。即使看不充分的科学行为和各种研究结果的陈述，一个人也很幸运地发现了与强大的安慰剂效应相匹配的结果。对许多临床医生来说，他们的任何治疗方法都不能令人信服地比安慰剂好，这一事实应该让他们质疑自己所做的事情，这应该成为改善临床实践的重要推动力。但是，不幸的是，我们总是太懒，太安于自己的习惯而不愿努力去改变。在所有这些事实中，我们都经历过（“几个”）患者从我们的治疗方法中得到改善，希望他们不都是由于自然过程和回归均值，很明显我们的模型是错误的。否则，我们会有更好的治疗效果。伟大的科学家理查德·费曼雄辩地描述了我们今天的临床状况：
If you want to create a habit, repeat your actions. If you want to create a beneficial habit then revise and reflect on your actions and their implications before you repeat. Looking at the state of the art-practice of chronic pain medicine one observes a repetitive action, an unsatisfying patient outcome and an occasional reflective practice that does not translate into altered clinical practice. I am not insinuating that everything the practitioners do is flat out wrong, only that they are close to clueless regarding what they actually do, when they should do what and to whom they should do it. So let us take a step back and evaluate what research as of 2016 has told us about both medical science in general and especially pain medicine (i.e., longstanding pain conditions). Chalmers, Glasziou and Ioannidis have all shown us that most published research is both unreliable and clinically irrelevant [1,2]. That is a serious enough problem in itself, but the truth is even worse. Hardly any published clinical findings are replicated [3] and thus confirmation of truly significant findings are usually non-existent. So far we know that most of our clinical knowledge is wrong and unconfirmed. In addition, we know that most clinicians fail to interpret research findings correctly [4]. Consequently, most clinicians will constantly face the possibility of violating the Hippocratic oath. Some salvation is provided by the immensely important work of researchers and clinicians that remind us of the importance of rigorous methods for synthesizing medical knowledge and providing them as (freely) available guidelines and recommendations [5]. Other scientific beneficiators are researchers that use high end randomized controlled trials to test what format of presenting summarized guideline information is most helpful for clinicians, when transforming information to knowledge for use in shared decision-making, a key component of person-centered healthcare [6]. Turning to longstanding pain conditions we know that chronic primary pain (e.g., low back pain, neck pain, fibromyalgia) is most likely the most expensive and disabling condition worldwide. To the medical community this fraught condition is without any documented effective treatment. In fact, to date there does not exist a single intervention in the field of chronic pain medicine, replicated by an independent research group, that has effect sizes that are both statistically significant and which demonstrate clinically relevant improvements relative to placebo interventions [7,8]. Even looking at insufficiently scientific conductions and presentations of various research results, one is lucky to identify results matching the powerful placebo effect [9]. To many clinicians, the bare fact that none of their procedures is convincingly better than placebo should make them question what they do and it should serve as a substantial driving force to improvement of clinical practice. But, unfortunately, we are all too often too lazy and comfortable in our own habits to make the effort to change. Include in all this the fact that we all have experienced (‘several’) patients’ improvements from our treatment approaches and they are hopefully not all due to natural courses and regression to the mean, it is evident that our models are wrong. Otherwise, we would have had better treatment outcomes. The great scientist Richard Feynman has eloquently described our clinical situation as of today: