Therapeutic effectiveness depends on propaedeutics

Abstract

It is now well known and a matter of consensus both nationally and internationally that decision-making for medicine and healthcare should generally be based on good scientific evidence, particularly from clinical trials and systematic reviews with meta-analyses when possible. 1This conviction regarding the strategies to be followed has expanded especially because of the benefits accrued for patients, whose chances of success have increased and chances of harm have decreased, along with ethical, legal and economic benefits. The Brazilian Ministry of Health's own experience has shown that the systematic reviews already conducted may have reduced the wastage of billions of reais per year on treatments of low efficacy that do not present advantages over traditional treatments, or that are even useless or harmful.2 All of this makes us believe that evidencebased decision-making is important for medical teaching and for healthcare managers.The same is true for continuing education or, better, continuous professional development for physicians, since it is more efficient and easier to keep up to date with quality evidence than to have to be satisfied with information of questionable value in terms of practical results, from studies motivated by a variety of interests but with scientific deficiencies. Such studies cause wastage of financial resources, and this ends up subtracted from salaries and medical fees, and from the funding for policies of known efficacy, such as vaccination, cardiovascular disease prevention, food safety, hospital hygiene, etc.However, everything said here so far starts from the principle that the diagnosis is correct and that the doubt lies only in what to do. But this is not so. Patients need to be heard calmly; complementary investigations need to be done carefully; physical examinations need to be detailed and not just directed; specialized physical examinations need to be competent and complete; differential diagnoses need to be based on wide-ranging medical knowledge; and approaches adopted need to have the good sense of aiming towards more benefit than harm for patients. In addition, patients need to be provided with information on the evidence regarding risks and benefits from each complementary and therapeutic diagnostic choice.It is here that undergraduate education is decisive. Over recent decades, with the clear value placed on scientific production from teachers and the absence of tools for evaluating teaching at the bedside (and for evaluating patients), basic education for future professionals has come to have little worth in teaching careers within medical schools. Professionals whose activities consist almost exclusively of research, preferably at the laboratory bench, have these activities measured in terms of the number of papers published (on their merits), but basic education for clinical practice is tending to disappear (and I think that this is not an exaggeration). My question is: who is going to care for the health of our grandchildren and subsequent generations?Despite...