Is there such a thing as ‘good medicine’ and ‘bad medicine’?
Yes, there is such a thing as good and bad medicine.
What is good medicine?
Good medical practice:
- Involves advice or treatment that has proven value or will not exacerbate the problem
- Is based on thorough understanding of anatomical, physiological and pathological mechanisms
- Is kind, caring and holistic; well communicated; and giving the patient confidence
- Appreciates the important role of psychosomatic symptoms in human disease
- Embraces an evidence-based approach to therapy (with appropriate levels of confidence).
What is bad medicine?
In contrast, bad medical practice:
- Involves advice or treatment that has no value or exacerbates the problem, and/or ignores placebo effectiveness
- Has flawed concepts of bodily function
- Is not kind, caring and holistic; poorly communicated; leaving uncertainty about the doctors skills
- Rejects psychological factors in the production of symptoms
- Is content with anecdotal evidence (involving inappropriately low levels of confidence).
Complementary and alternative medicine (CAM)
In most Western developed countries, complementary and alternative medicine (CAM) is divorced from conventional (‘scientific’) medicine. This means that patients can only benefit from the best of both systems by dividing their care. Science must be used to stimulate convergence of complementary and conventional healthcare.
First class research to examine the more interesting claims of CAM is essential to broaden the range of therapeutic options available, while minimising fraudulent, ill-informed and sometimes dangerous practices.
Mutual respect and interest between orthodox and alternative practitioners is appropriate, but there can be no compromise involving unscientific approaches to care.
Accepted level of scientific ‘proof’ in conventional medicine
It is noteworthy that the threshold for good evidence (‘proof’) in conventional medicine is low. Controlled trials use the relatively low ‘p value’ of <0.05, as evidence of showing the trial is ‘positive’ (i.e. shows a meaningful difference between a treatment and control group).
It is also conventional to state that a NNT (number needed to treat) of 25 or more is satisfactory for a new treatment. This means it only has to benefit 1 in 25 patients to be considered ‘useful’, i.e. 24/25 patients may have no benefit but be subjected to risk and side-effects.
Oh yes
And we should avoid an over obsession with us (as doctors) as the providers of good (or bad) medicine. As ‘good medicine’ is entirely dependent on good nurses, allied health professionals, GP and ward receptionists, ward clerks, managers, cleaners, porters, and everyone in the NHS. We are all in it together.
Summary
When you are caring for and treating patients, you need to challenge yourself against these criteria every day. Do not disrespect CAM, and be aware of the lack of evidence for conventional medicine. And remember you are only as good as the team.
Other resource
Review article: Dwyer, 2004
