Evidence-based medicine and domestic medical science .
In the past twentieth century, clinical medicine has made stunning progress: it was created by antibiotics, vaccines, hormones, anti-hypertensive and anti-tumor agents that have saved and extended the lives of millions of people. Dizziness manifested a progressive increase in the number of professionals engaged in clinical and theoretical medicine, there are a large number of medical journals, the shaft of scientific works and publications. The basis for this was a thousandfold increase in healthcare funding. So, in 1991, U.S. spending on health care amounted to 752 billion, or 13.2% of gross national product.
In this regard, in the society, spending on medical science huge funds, the question arose: how exactly the money is spent, who spends them, and to whom is this money allocated in the future? . Even in the most economically developed countries, the question arose of a choice of optimum medical interventions – with a high ratio of their clinical effectiveness and cost.
On the other hand, most of the medical community and, equally important, health care providers, there is a question: the Results of what works should be trusted? What results to use as a guideline for practical public health? . To answer these questions in the 80-ies of XX century developed the concept of docusateennosides ( evidence based medicine ), which the pioneers of clinical epidemiology Robert and Susan Fletcher  is defined as medical practices based on the results of properly designed clinical trials. In accordance with the concept of evidence-based medicine every clinical decision of the physician must be based on scientific facts, and the weight of each fact becomes the greater, the stricter methodology of the studies in which this fact received.
During the discussion of the principles of evidence-based medicine can hear the objection that they are questioning the value of all the medical knowledge that accumulated over the millennia. However, evidence-based medicine involves more advanced research methodology medical interventions with non-obvious efficiency corresponding to modern planning of scientific experiment. Only the results of such studies are recognized as evidence-based, that is evidence.
Indeed, the effectiveness of the harness for bleeding to prove is quite simple: since its imposition, it stops. It is obvious that this intervention is effective. Similarly is the case with hormone replacement therapy. Classic experimental endocrinology of the NINETEENTH century was based on the removal of endocrine glands and demonstration of the developed regression changes by introducing into the body of an experimental animal extract of this gland. As exhaustively conclusively the effect of insulin in the treatment of diabetes mellitus type 1 and preparations of levothyroxine in treatment of hypothyroidism. In this case, the theoretical ideas of the researcher about the causes of disorders of the pathophysiological coincide with the objective facts and therefore confirmed the clinical practice.
Much more difficult is the problem of different therapeutic interventions is in those cases when an attempt to influence the pathological process, which is a cascade of interrelated biochemical reactions that are deployed in the cell itself and its surrounding structures. The dynamics of chain reactions, the signals that determine their beginning and end, as a rule, remain unknown. As a result of the pathological process, is a holistic dynamic system can be reduced to the particulars: the fragments and the links of individual biochemical reactions, which are often sent to numerous pharmacological effects. In these cases, the implementation of theoretical assumptions, even based on high-tech experimental data does not lead to obvious clinical effect. So, for example, is the case with the use of different classes of angioprotectors in atherosclerosis or diabetic angiopathy, clinical trials which in the framework of randomized trials have not yet led to a positive result. The concept of evidence-based medicine the theoretical understanding of the pathogenesis of (usually incomplete), opinions of authoritative experts, tradition, personal experience, considerations of priority are not considered conclusive, scientific basis for the use of a particular medical intervention. The value of theoretical ideas about the properties of drugs is indisputable, however, their true therapeutic potential can only be determined in clinical trials performed by the rules adopted by the international medical community.
In the journal “British medical journal”  published an article with a comic listing the options for medical practices that are not based on proven facts , as opposed to evidence-based medicine. The authors rightly point out that if a medical practice is not based on proven facts, it is based on.
The authority of the doctor ( the increase in the number of similar errors with increasing experience.
The passion ( emotional impact on a more relaxed colleagues and relatives of patients.
On the appearance and eloquence ( nice tan, silk tie, impressive pose and eloquence as a replacement for proven facts.
On Providence ( where nobody knows what to do with the patient instead of an informed decision is God’s will.
The feeling of insecurity ( feelings of confusion and despair, the solution is not accepted.
To nervousness ( in the constant fear of the judicial process, the doctor will prescribe, excessive examination and treatment.
On self-confidence ( mainly for surgeons.
By modern standards, a reliable evaluation of the effectiveness of the methods of treatment and prevention can only be obtained in randomized controlled trials – the most evidence-based and objective. Such tests are performed not only for pharmaceuticals but also for surgical treatment, physiotherapy, activities in the field of medical care, diagnostic methods. At the end of the study compares the frequency of occurrence of clinically important outcomes – recovery, complications, death, and not surrogate outcomes – changes in physiological, biochemical, immunological and other parameters. Thus, estimated not so much the immediate results (laboratory, instrumental, etc.), how many remote (clinical effects, were set as the end points of the study.
To obtain the findings of the study must consider the uncertainty of many parameters, and the finite number of observations. The most appropriate tool in this case are statistical methods. This feature highlights one of the definitions of statistics given by the American mathematician A. Wald – statistics – a set of methods that allow us to make optimal decisions in conditions of uncertainty.
Why domestic medicine has not yet gone the way of evidence-based medicine, and the work of Russian authors stand out and casuistically rarely quoted abroad? Why national medical journals have such a low rating compared to foreign? The reasons, probably a lot.
First, the domestic medicine has not experienced such a powerful economic incentives and never funded at the levels outlined above.
Unconditional second factor is the prolonged isolation of the Soviet medical science of the world, and some of this insulation had a demonstrative character, and works of domestic authors was opposed to foreign. So far, the list of references of the article or dissertation is seen by many not as a list of cited literature, and as a kind of independent work in which a certain fraction of the sources must belong to the native authors. Paradoxically, along with the criticisms of the bibliography, in some cases, you can not hear any criticisms of the work itself.
The fact that all, without exception, the domestic medical journals published in the Russian language, does not justify the low ranking of these journals in the scientific world. In this respect, a good example are published in German language journals of a German company or Wochenschrift ACTA Medica austriaca and which have high international rating, and sometimes traditionally more fully sanctify some problems.
The consequence of these factors was a serious discrepancy methodological base of the Russian medical science with modern international standards receive research-based, evidence-based research results. According to the modern view, these are the results of studies that meets the following requirements.
Compliance with the way of organizing the research task.
Minimization of systematic errors.
in the formation of unbalanced groups of observations.
due to improper and non-standardized measurements.
due to confounding factors.
To minimize random errors by correct data analysis.
The presence in the study of the systematic errors and the lack of ways of the organization of the study the tasks makes the study meaningless. No, even the best data analysis cannot compensate for defects in the organization of the study . As a result, the conclusions appear to be unfounded. At the same time, properly organized study in which data analysis is performed correctly, it also negates all the efforts of the researchers.