CMAJ • March 2, 2004; 170 (5). doi:10.1503/cmaj.1031733.
© 2004 Canadian Medical Association or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters
Correspondance

Practising sound medicine in the absence of evidence

Fiona Kouyoumdjian and Vanessa L. Cardy

Medical Students, Dalhousie University, Halifax, NS

The commentary by Harriet MacMillan and Nadine Wathen1 illustrates some of the problems that may arise in using only an evidence-based approach to guide clinical decision-making, rather than balancing existing evidence with clinical judgement. Although it was perhaps not the authors' intention, we are concerned that the message that physicians may take from this article is that they should not screen for abuse because evidence for such an intervention is inadequate.

There is a marked paucity of research in this field, particularly given the pervasiveness of abuse and the injuries and deaths it causes. If we are to use only those interventions for which significant (statistically or otherwise) research has been done, then we may be systematically excluding interventions for which there has been less academic interest and consequently less published research on which to base recommendations.

The suggestion to screen people with signs and symptoms of "potential abuse"2 is confusing. Although research has been done on the prevalence of various signs and symptoms in people who have been abused,3 the predictive value of signs and symptoms has not been high,4,5 which suggests that they are not sensitive indicators of abuse. This, coupled with the high prevalence of abuse, justifies universal screening: if, as the authors state, it is appropriate to screen people exhibiting signs and symptoms, then it should be appropriate to screen everyone.

Finally, it appears that the authors did not consider that the act of disclosing to a health care provider an experience of abuse may be a positive outcome in and of itself, if the disclosure is beneficial psychologically.

Given the apparent lack of harm in screening patients for abuse and its potential benefits, which have yet to be adequately investigated, we feel that this intervention should continue to be widely used until further research demonstrates that it is inappropriate or unnecessary.

Fiona Kouyoumdjian Vanessa L. Cardy Medical Students Dalhousie University Halifax, NS

References

  1. MacMillan HL, Wathen CN. Violence against women: integrating the evidence into clinical practice [editorial]. CMAJ 2003;169(6):570-1.[Free Full Text]
  2. Wathen CN, MacMillan HL, with the Canadian Task Force on Preventive Health Care. Prevention of violence against women. Recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 2003;169(6): 582-4.[Free Full Text]
  3. McCauley J, Kern DE, Kolodner K, Dill L, Schroeder AF, DeChant HK, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123 (10):737-46.[Abstract/Free Full Text]
  4. Wasson JH, Jette AM, Anderson J, Johnson DJ, Nelson EC, Kilo CM. Routine, single-item screening to identify abusive relationships in women. J Fam Pract 2000;49(11):1017-22.[Medline]
  5. Saunders DG, Hamberger LK, Hovey M. Indicators of woman abuse based on a chart review at a family practice center. Arch Fam Med 1993;2 (5): 537-43.[Abstract/Free Full Text]




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