Medisinsk kunnskap før og nå:Fra teori til systematiske oversikter
DOI:
https://doi.org/10.5324/nje.v23i2.1631Abstract
Teorien om balansen mellom de fire kroppsvæskene – humoralpatologien – dominerte sykdomsforståelse og dermed også medisinsk behandling i 2000 år. Brekkmidler, årelating og avføringsmidler var hyppig brukte virkemidler for å rette opp i ”ubalanse” mellom kroppsvæskene, som var regnet som årsak til sykdom.
Det var ikke før på 1700-tallet at faktisk empirisk kunnskap ble etterspurt som begrunnelse for valg av behandlingsmetoder. Det å telle opp hvordan det gikk med pasienter som fikk en behandling, og sammenlikne med pasienter som ikke fikk behandlingen, var en ny måte å presentere behandlingseffekter på. Fra 1800-tallet av er det mange eksempler på at behandlingsmetoder ble prøvet ut ved å la annenhver pasient motta behandlingen.
Streptomycinstudien til UK Medical Research Council (1946) regnes for å være det første randomiserte kontrollerte forsøket innen medisinsk forskning, og for å ha satt standarden for hvordan kliniske utprøvninger bør utføres.
I boka ”Effectiveness and Efficiency. Random Reflections on Health Services” (1972) kritiserte Archie Cochrane mangelen på dokumentasjon for mange av tiltakene som utføres i helsetjenesten. Han ønsket seg langt flere randomiserte studier. Dessuten tok han til orde for at alle randomiserte studier burde samles, og at resultatene burde oppsummeres jevnlig. Iain Chalmers tok utfordringen og påbegynte et omfattende arbeid med å utarbeide en database over randomiserte kontrollerte forsøk. Med utgangspunkt i denne databasen ble det så utarbeidet systematiske oversikter over gjeldende kunnskap om effekt av tiltak i helsetjenesten. Dette ble starten på Cochrane-samarbeidet.
Fretheim A. Medical knowledge then and now: From theory to systematic reviews. Nor J Epidemiol 2013; 23 (2): 113-118.
ENGLISH SUMMARY
The humoral medicine-theory dominated the understanding of diseases and thus also medical treatments over 2,000 years. Purgatives, bloodletting and laxatives were frequently used to correct ”imbalances” between body fluids, which were seen as the cause of disease.
It was not until the 18th century that actual empirical knowledge was seen as important as a basis for making decisions about choice of treatment. At this time, the idea of counting the outcomes among patients receiving a treatment and compare with patients who did not, was a new approach for presenting treatment effects. As of the 19th century there are many examples of treatments being tested by the use of alternation, i.e. allocating every other patient to the treatment under evaluation.
The UK Medical Research Council’s streptomycin-trial (1946) is regarded as the first randomised controlled trial in medicine, and for having set the standard for clinical trials.
In his book, ”Effectiveness and Efficiency. Random Reflections on Health Services” (1972), Archie Cochrane criticised the lack of evidence for many of the interventions being performed in the health services. He called for far more randomised trials. He also proposed that findings from randomised trials should be collated, and that the results should be summarised on a regular basis. Iain Chalmers took the challenge and engaged in the huge task of developing a database of randomised controlled trials. With the database as a starting point, several systematic reviews of current evidence on the effects of interventions in the health services were produced. This was the start of the Cochrane Collaboration.
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