This past week, I spoke at the 2nd Annual Trauma Spectrum Disorders Conference, which is a scientific conference on the impact of military service on families and caregivers, held on the National Institutes of Health campus in Bethesda, MD. Many government agencies collaborated, including NIH, the Department of Defense, the Veterans Administration, the Department of Health and Human Services and others. I applaud these agencies in their efforts on behalf of those who have borne the burden of our recent military campaigns in Iraq and Afghanistan. The focus of the conference was on translation of research findings into clinical care and policies and identification of priority areas needing additional research. This conference offers a good example of the challenges of evidence-based medicine (EBM).
The fact is that using research findings to guide care is seldom straightforward. Most areas of medical care do not have high level research evidence underlying them. Even where high-level evidence is present, applying it is not easy. Most high-quality studies are highly controlled efficacy trials in academic health centers. In order to isolate the question being investigated, study participants are carefully selected. People with other serious medical, psychiatric or substance use disorders are often excluded, as are people with no transportation or who have to work two shifts a day to make ends meet. Studies are usually time-limited, although most diseases are chronic. The level of care provided in efficacy trials is almost always higher than that in usual care. Thus, generalizing findings from efficacy trials to community care is difficult, because patients in the community differ in systematic ways from study participants and community care necessarily lacks the rigor present in efficacy trials. For example, in an excellent NIH-funded study comparing different treatments for attention deficit disorder (ADD), stimulant medication was found to be a highly effective when rigorous medication management procedures were employed, but was not at all effective as used in common practice where systematic follow-up and careful medication treatment protocols were absent.
A related problem is that clinical research is very expensive and time-consuming. Thus, clinical realities often race ahead of the research. Neither clinicians nor consumers feel they can wait for the next study before acting. This is certainly the case for military service members and their families. Many medical advances, especially in trauma care and surgery, are made on the battlefield out of desperate necessity. Exposure to battlefield conditions may lead to previously unknown disorders, such as Gulf War Syndrome, that nevertheless require treatment (and determinations regarding disability.) It has taken a long time to address Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI) and the disorders that often accompany them such as substance use and other psychiatric disorders. Management of chronic pain remains controversial and difficult. Spouses, children and extended family members of those who are serving also experience serious stress including financial strain, prolonged absence of their loved one and having to care for a veteran with service-related injuries including PTSD and TBI. In none of these areas is there a strong evidence base providing guidance. Yet, we have a responsibility to do what we can. That’s what I spoke about today, and I’ll discuss that more in a future post.