Clinicians employ principles of epidemiology for decision-making, consciously or subconsciously.1 Though this is well known, teaching and practice continue to be based on case studies, partially endorsed or unendorsed reviews, and anecdotes. Clinicians fail to appraise the evidence critically because of a poor understanding of research methodology. Therapies backed by ample evidence are underused because of a lack of knowledge or because clinicians believe that results observed in clinical trials cannot be translated into clinical practice.2 Not surprisingly, only 15% of medical interventions are based on solid scientific evidence.1 Clinical medicine appears to consist of a few things we know, a few things we think we know (but probably dont), and lots of things we dont know at all.3
In India, epidemiology is well established and mandatory in undergraduate medical training as part of Social and Preventive Medicine. Evidence-based medicine is a fashionable topic known to medical personnel with international exposure but it is yet to be routinely practised. Between November 2001 and January 2002, we performed a survey in three teaching and three non-teaching hospitals in New Delhi to elicit perceptions about epidemiology and its uses from 190 clinicians. We used a questionnaire consisting of 13 items, divided into five broad groups: (1) perception of epidemiology, (2) enthusiasm for taking up epidemiology as a career, (3) status of epidemiology, (4) attitude to epidemiology, and (5) need for training. Each respondent was asked to answer each item with his/her degree of agreement on a four-point scalestrongly agree, tend to agree, no opinion, and disagree. Public health professionals and clinicians already exposed to epidemiological training were excluded from the survey.
Of 190 selected clinicians, 151 (79.5%) responded: 32 internists (21.2%), 27 ophthalmologists (17.9%), 26 gynaecologists (17.2%), 10 gastroenterologists (6.6 %), and 24 from other specialties (15.9%); 18 were non-specialists (11.9%), and no specialty was reported by 14 (9.3%). Results of the survey are presented in the Table. A surprisingly high proportion of the clinicians in this survey agreed that epidemiology is a basic science for clinical medicine and therefore necessary for a good clinician (86.1%). The enthusiasm for taking up epidemiology as a career was considerable (41.6%), in particular if better research and job opportunities were provided and a modified, integrated curriculum was introduced (60.9%). While 136 respondents (90.1%) concurred that sound knowledge of epidemiology was necessary for a good clinician, about a third felt that a trained epidemiologist lacked clinical knowledge and was a waste of time for clinicians. A high proportion of respondents felt that epidemiology was a postgraduate subject choice for graduates of lower rank (62.9%).
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The low opinion of epidemiology, particularly among internists, is not entirely unexpected. Even David Sackett, one of the founders of evidence-based medicine, realized the importance of epidemiology and its relevance to clinical medicine rather late.4 Clinicians often refrain from formally applying the tools of epidemiology during clinical decision-making, tend to be categorical in expressing clinical outcomes, are uneasy about uncertainty, and are reluctant to express this uncertainty using probabilities.5
Ever since its foundation in 1954, the International Epidemiological Association has been concerned with education about and promotion of the wider application and use of epidemiology. However, no special emphasis for clinicians had been made. Subsequently, under the auspices of the International Clinical Epidemiology Network (INCLEN), faculties from six identified institutions in India were trained abroad, so that they in turn could develop local and regional capacity and expertise. However, it appears that further dissemination of this knowledge has not taken place. Apparently the trained could not become trainers as envisaged.
This survey indicates a need to have new look at the issue of epidemiological training for prospective clinicians in India. Reorganizing the undergraduate and postgraduate medical curricula may be necessary, particularly in the field of internal medicine. Integrating epidemiology with clinical teaching, using relevant examples to make it more interesting and easy to comprehend and supplementing the formal classroom teaching of epidemiological methods with teaching sessions during ward rounds might be helpful.
References
1 Smith R. Where is the wisdom? BMJ 1991;303:79899.[ISI][Medline]
2 McMurray JJ. Failure to practice evidence-based medicine: why do physicians not treat patients with heart failure with angiotensin-converting enzyme inhibitors? Eur Heart J 1998;19(Suppl.L): L1521.[Medline]
3 Naylor CD. Grey zones of clinical practice: some limits to evidence-based medicine. Lancet 1995;345:84042.[ISI][Medline]
4 Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology: a Basic Science for Clinical Medicine. Boston: Little Brown, 1985.
5 Fletcher RH, Fletcher SW, Wayner EH. Clinical EpidemiologyThe Essentials. Baltimore: Wilkins and Wilkins, 1989.