Consider the evidence carefully

A number of years ago, the major medical journals introduced the structured abstract for most original research articles. The goal was to make it easier for us as readers to determine how relevant the new material might be for patients we were seeing in the clinic.

An important part of the abstract is a brief section on "limitations" of the study, which further helps us evaluate the relevance. From this very helpful advance a new science has evolved — systematic reviews and meta-analyses.

In many areas of medicine and public health this has been a major advance, but one area where I am still having difficulty is the vitally important issue of pharmaceutical trials; in particular when trying to decide which of the new classes of medication is best suited to the patient sitting opposite me in the clinic.

For very practical reasons most trials have to recruit a very specific, carefully selected group of study subjects often to the exclusion of those patients who have multiple medical problems or are on multiple therapies (ie, most of our patients). That's where we have to very carefully read the data to see how closely our patient matches up to those in the study and to make certain that the comorbidities and concurrent medications might make this apparent major therapeutic advance potentially hazardous. That is no easy task and you might not like my suggestion for how to handle it: Be patient!

Increasingly, our patients know about these "advances" before we have had access to the original article and they think that the few paragraphs on the front page of the newspaper tells them (and you) all that needs to be known. The patient has been waiting for this "breakthrough" for some time and you are suggesting that they wait a bit longer so we can learn more about it! Sit tight, and as adroitly as possible let the patient know that it is in his or her best interest that you do due diligence before writing a prescription.

Every now and then there is indeed a major pharmaceutical breakthrough in an area where our current drugs are not very effective, but that is not always the norm.