I've just got round to reading the June 2001 issue of Clinical Evidence the 'compendium of the best available evidence for effective health care' that now plops on the door step of all GPs every 6 months.
Two things strike me.
First, the amount of effort that has gone into compiling it. All those Cochranesque researchers around the world ferreting through all the studies, discarding the duds and tracking down the unpublished stuff for their systematic reviews. Millions of hours of evidence-based effort condensed into nearly 1500 pages.
Second, nothing seems to work as well as everyone thinks it does.
Chapter one: clot-busting drugs for heart attacks. I mean, who wouldn't want to have that nasty old thrombus dissolved? Most patients (and a fair few doctors) would assume that all patients given such high-tech medicine would gain from it, but the number needed to treat to save one life is 56.
Or, if you prefer, if we treat 56 people with myocardial infarctions only one will benefit and the rest will be at risk of a major bleed for no benefit.
And what's more, we don't give thrombolysis in the community so we build whole departments of coronary care around this statistic. Even in a busy unit thrombolysing 20 patients at a time, the chances are that none of the patients will benefit. Is this value for money?
At the low-tech end of the spectrum, the impotence of scientific medicine is equally evident. Page 372: 'We found no good evidence of the benefits of mechanical removal of wax.'
Now, I know absence of evidence isn't the same thing as evidence of absence, but ear syringing is a dangerous business.
One study of 274 GPs who performed it found that 38% reported complications. Otitis externa, skin damage, perforation of the tympanic membrane, tinnitus, pain, vertigo
I still have my copy of Cautionary Tales, given to me by the MDU on qualification, which gleefully documents loose syringe nozzles ending up in the brainstems of unsuspecting patients.
I don't know how much time we've wasted over the years squirting water at wax, but learned behaviours die hard and a friend of mine who tried to refuse a syringing, citing Clinical Evidence, June 2001, nearly ended up with the equally well documented nozzle in the rectum.
Patients don't like being told they can't have what they've had for generations, even if controlled trials show it to be quite useless.
Ear syringing and other inane daytime activities tend now to be devolved to the poor practice nurse, but an Oxford medical student who's recently done his GP attachment has come up with a brilliant idea to take the strain off GPs and nurses alike.
Forget EBM, what you need is MLM (that's mid-life mothers).
Women in their 50s with the kids at school are often a bit isolated and looking for a career change. As parents, they're highly trained in the art of healing, and can provide as good a shoulder to cry on as anyone.
What's more, most mid-life Mums know all about contraception, screening, childhood ailments, minor illness, depression, women's problems and caring for elderly relatives which covers a huge chunk of general practice.
They could be trained as clinical assistants and employed in surgeries for a salary that doesn't break the NHS bank.
And they could triage out the mundane patients, leaving GPs and nurses as Yoda-like figures in a back room waiting for their underlings to bring them their problems and queries.
It would restore the wisdom and self-esteem of GPs and nurses, and create jobs for disaffected housewives who'd otherwise be patients. And guess who'd do the ear syringing?