Tell the GMC that we need Evidence Based Practice

I have just responded to the GMC consultation on Good Medical Practice (GMP). Staggeringly, the questionnaire does not ask about evidence based practice. So I submitted this text in the `general’ section at the end.

Section 14b of the draft guidance states:

“In providing care you must…. Provide effective treatments based on the best available evidence.”

However the guidance does not define what evidence is. As such, it is likely to cause confusion among doctors and among the public. There are many registered doctors who administer treatments on the basis of anecdotal and other poor quality evidence. Very occasionally, these doctors have been disciplined by the GMC. I envisage in future such doctors being brought before the Fitness to Practise panel, and engaging in convoluted arguments to the effect that they used the best available evidence, even though that evidence did not meet the accepted `gold standard’. The GMC needs to make clear its expectation in this regard. I therefore propose expanded wording as follows:

Doctors must provide effective treatments based on the best available evidence. Where the evidence is inadequate (for example where high quality clinical trials have not been published), doctors must be prepared to justify their choice of treatment when challenged, taking the risk:benefit assessment into account. Where there is significant evidence that shows a treatment to be ineffective, doctors should not use the treatment.

In all cases, doctors must effectively inform patients as to the evidence available for the treatment prescribed, and informed consent must be documented.

Evidence must be taken to include:

  1. High quality randomised controlled trials (RCTs). Quality must be established by a recognised grading scale (ref).
  2. Systematic reviews and meta-analyses.
  3. Other research which demonstrates generalisability to normal clinical practice, but only when underpinned by RCTs. For example uncontrolled observational studies are useful as an adjunct to RCT evidence.

Evidence that relies solely on anecdotes (ie patient testimonials), poor quality RCTs, uncontrolled studies, patient surveys, and similar non-rigorous studies, must not be used to justify a treatment choice.

These provisions apply to treatments where the outcome has previously been in doubt. For example, the efficacy of setting broken bones is not in doubt, and does not require RCT evidence.

Reference

Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Controlled Clin. Trials 1996; 17: 1-12.

I have not said it explicitly, but I have taken it as read that doctors must not knowingly prescribe placebos. I think this is fairly well established anyway.

If you haven’t responded yet, do so now – you have until Friday 10th February (2 working days from the date of this post). You will need to register, but it’s a very quick process.

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2 Responses

  1. “I have taken it as read that doctors must not knowingly prescribe placebos”

    That’s a tad questionable as there some limited contexts in which it may be ethically permissible to knowing prescribe a placebo, although these generally fall within the field of psychiatric medicine and are not at all common in general practice.

    • You may be right Unity, but I should think those circumstances are extremely limited, eg where the patient has no insight into their illness and is unable to give informed consent. I am happy concede the point though.

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