Abstract
David Sackett’s death earlier this year earned widely published obituaries. Known as the father of evidence-based medicine, Sackett transformed the way clinicians, researchers and medical editors think about evidence. Sackett challenged orthodoxy and the lazy assumptions of experts. In this month’s article from the James Lind Library, in possibly his last contribution to a medical journal, Sackett explains why he became a clinician-trialist. 1
As Sackett developed as a clinician and his diagnostic skills improved, he became increasingly frustrated with the ‘profession’s collective ignorance’ about how he should treat patients or whether he should treat them at all. These frustrations shaped Sackett’s career, influenced the profession whose collective ignorance he disliked and helped patients receive better treatments.
Researchers and students of methodology in doubt over the reasons for four of the fundamental pillars of randomised controlled trials will find a clear explanation in Sackett’s account. His observations and experiences influenced the establishment of random allocation of treatments, concealment of treatment allocation from patients and clinicians, intention to treat analyses and blinded outcomes assessment.
The importance of evidence is underlined by one of this month’s research papers. Chana et al. 2 examine the sacred cow of using cardiothoracic ratio on chest X-ray to detect cardiac dysfunction. In a retrospective analysis of 400 patients at two UK hospitals, the researchers find that, in the context of an acute admission, cardiothoracic ratio measured on postero-anterior or antero-posterior chest X-rays has limited value in detecting ventricular dysfunction.
You sense that Sackett would have approved of the questioning nature of this study. Challenging the profession’s collective ignorance may be hazardous for clinicians but generally reduces the hazard that patients are exposed to. Iconoclasts, alive or dead, will never be short of admirers.