This is the title of a very sensible rapid response from Julian Tudor Hart in the BMJ in October 2005, and he has given permission for me to quote him in this newsletter, (see below).
I entirely agree that it is not possible to consider bald evidence without considering the ‘story’ or ideology that has inspired the work that produced the evidence. This story may have a major bearing on the interpretation of the results of any study, or for that matter systematic review.
In the same way that ideology always interacts with evidence, it is a false division to try to look at evidence based medicine and narrative based medicine as if they are opposite methods of practice. As I have tried to point out in the recent interview for Doctor Magazine, consulting in medicine needs to consider the patient’s agenda, their ‘story’. Patients do not present complaints alone, but usually have interpreted them after discussion with friends or family members. If we never dig out their story the patient is unlikely to be satisfied with the consultation, and dysfunctional consultations may result when the patient’s story has a completely different set of assumptions to the doctor’s story of what the symptoms might mean.
The publication of a trial testing a new treatment is designed to tell a story from the sponsors which might read along these lines: “this is an excellent new product that your patients will benefit from.” Inevitably this will influence the way results are presented, and which of the huge quantity of outcome data collected is presented to the readers. Registration of clinical trials and publication of trial protocols should help to reduce publication bias of this kind, but one of the fascinations of reading reports of trials is to look underneath the results to the underlying ‘story’, and see how this colours the way the data is presented.
As you read you may wish to reflect on your own pre-existing ideas about the clinical question being asked. What are your assumptions? How do these differ from the authors’ assumptions? Is there a bigger picture? Are the outcomes presented the ones that the treatment has the best chance of influencing? How does this relate to the outcomes that really matter to the patient? Have adverse advents been considered, and have enough patients been studied to detect serious but rarer events?
Evidence should be considered with its ideological framework, just as symptoms need the context of the patient’s story so that we can see how they make sense to their owner!
Hart JT. Evidence not ideology: No evidence is without ideology. BMJ 2005; 331:964
“No evidence is without ideology
EDITOR—Godlee asks for evidence without ideology, as though it were possible either to discover or use evidence without ideology of some kind. Scientific evidence is derived from hypotheses conceived within an ideology—that is, a set of prior assumptions about the real world, established by previous evidence, by faith, or by both. New evidence can then be produced by testing hypotheses derived from those assumptions against reality. The validity of competing hypotheses, including those macro-hypotheses about the world or society we call ideologies, depends on their explanatory and predictive power in the real world.
About the private finance initiative and the Blair government’s disintegration of the NHS into a competitive market led by consumer wants rather than by national health needs, nobody has published more evidence than Pollock. For the editor of the BMJ to dismiss this as led by ideology is an impertinence. Without exception, every paper published by the BMJ starts from ideological assumptions of some kind. That the editor’s assumptions apparently coincide with those of currently fashionable and conventional opinion does not change their ideological nature. Readers can make their own judgments as to which ideology has most explanatory and predictive power, either experimentally or in the more chaotic real world of practice, which in the absence of pilot projects is all we have to go on in assessing the consequences of marketisation.
This is a deadly serious business. Asked to describe the nature of the corporate state in the 1920s, before the full consequences of fascism were understood by comfortable people outside Italy, Mussolini answered that in his state the worlds of government and business would become one and indivisible. Godlee should consider how far we have already travelled along that road, and then reconsider the ethics of neutrality in such a situation. At the birth of the NHS, the BMJ had a role of which its later editors were frankly ashamed. Today, when the NHS is being buried alive, has it lost the power of speech?
Julian Tudor Hart, retired general practitioner
Primary Care Group, Swansea University Clinical School, Swansea SA2 8PP firstname.lastname@example.org”