TREATMENTS - BETTER RESEARCH
An editorial in
the British Medical Journal some years ago carried an arresting title:
‘The scandal of poor medical research’.83 The author called for less
research, better research, and research done for the right reasons. In
earlier chapters we have shown the kind of things that were bothering
FOR BETTER HEALTHCARE
CHAPTER VI - Excerpt
LESS RESEARCH, BETTER RESEARCH,
AND RESEARCH FOR THE RIGHT REASONS
For most of the
organisations supporting biomedical research and most of the
researchers doing it, their stated aim is straightforward: to
contribute information to improve people’s health. But how many of the
millions of biomedical research reports published every year really do
make a useful contribution to this worthy cause?
Researchers in Bristol decided to pose a fundamental question: ‘To what
extent are questions of importance to patients with osteoarthritis of
the knee and the clinicians looking after them reflected in the
research on this condition?’84 They began by convening four focus
groups – of patients,
rheumatologists, physiotherapists, and general practitioners,
respectively. These groups were unanimous in making clear that they did
not want any more trials sponsored by pharmaceutical companies
comparing yet another non-steroidal anti-inflammatory drug (the group
of drugs that
includes, for example, ibuprofen) against a placebo (dummy drug).
Instead of drug trials, participants in the focus groups wanted
rigorous evaluation of physiotherapy and surgery, and assessment of the
educational and coping strategies that might help patients to manage
this chronic, disabling, and often painful condition more successfully.
Of course, these forms of treatment and management offer much less
scope than drugs for commercial exploitation so are too often ignored.
A MOUNTAIN OF INFORMATION
‘Over two million articles are published annually in the biomedical
literature in over 20,000 journals – literally a small mountain of
information . . . In a stack, [the articles] would rise 500 metres.’
Mulrow CD. Rationale for systematic reviews.
In: Chalmers I, Altman CD, eds. Systematic reviews. London: BMJ Books,
How many other fields
of therapeutic research would, if evaluated in this way, reveal similar
mismatches between the questions about treatment effects that matter to
patients and clinicians, and those that researchers are addressing?
Other examples85, 86, 87 lead us to suspect that mismatch is the rule
rather than the exception. Minor changes in drug formulation rarely
lead to the drugs having substantially new, more useful effects, yet
these types of studies dominate research into treatments for arthritis
and for other disorders. What a waste of resources!
Clearly this situation is unsatisfactory, so how has it come about? One
reason is that what gets studied by researchers is distorted by
external factors.88 The pharmaceutical industry, for example, does
research for its primary need – to fulfil its overriding responsibility
to shareholders, not to patients and clinicians. Businesses are driven
by large markets – such as women wondering whether to use hormone
replacement therapy, or people who are depressed, anxious, unhappy, or
in pain. Yet only rarely in recent decades has this commercially
targeted approach led to important new treatments, even for ‘mass
market’ disorders. Rather, within groups of drugs, industry has
produced many very similar compounds – so-called ‘me-too’ drugs. This
is reminiscent of the days when the only bread available in
supermarkets was endless variations on the white sliced loaf. Hardly
surprising, then, that the pharmaceutical industry spends more on
marketing than on research.
But how does industry persuade prescribers to use these new products
rather than existing, less expensive alternatives? A common strategy is
to commission numerous small research projects showing that the new
drugs are better than giving nothing at all, while not doing any
research to find out whether the new drugs are better than the existing
ones. Regrettably, industry has little difficulty in finding doctors
who are willing to enrol their patients in this fruitless enterprise.
And the same doctors often end up promoting the products studied in
this way.89 Drug licensing authorities often make the problem worse by
insisting that new drugs should be compared with placebos, rather than
with existing effective treatments.
Commentaries in prestigious medical journals such as The Lancet90 have
drawn attention to the perverse incentives now driving some of those
involved in clinical research, and the increasingly dubious
relationships between universities and industry. One editorialist in
the New England Journal of Medicine91 asked bluntly ‘Is academic
medicine for sale?’
However, commercial priorities are not the only perverse influences on
patterns of biomedical research that disregard the interests of
patients. Many people within universities and research funding
organisations believe that improvements in health are most likely to
stem from attempts
to unravel basic mechanisms of disease. So, they do research in
laboratories and with animals. Although such basic research is
unquestionably needed, there is precious little evidence to support
this bias towards it.92, 93 Yet the consequence has been a massive
outpouring of laboratory research that has not been properly evaluated
to see how relevant it is to patients.