Palliative medicine: A practice of evidence or experience?

This paper will suggest that palliative care medical practice is seldom driven by research findings and if it is, these are unlikely to be from work by the field itself. Practice changes more as a result of case experience, both personal and.from case series. Increasingly, innovations (good and not so good) are transmitted by internet groups such as 'palliativedrugs.com rather than by journal articles and trials. New approaches to patient management are rapidly tested out in practice and transmitted around the world. The expensive and time-consuming nature of clinical trials means that many of these are never tested in this rigorous way. The only arbiter seems to be the Canadian historian Michael Ignatieffs covenant with his readers: "I have found this, now is it true for you?"

The modem evidence-based medicine movement has tried to imbue the whole of medicine with a rigorous approach to practice based on good quality studies and this is clearly correct. However, all good ideas have the potential to overshoot and become oppressive. Many questions and therapies will never be subjected to clinical trials but will rise or fall on personal or local experience, Whilst it seems without question that good quality trials should be designed for important therapeutic questions, it is disastrous, if clinical experienceis trivialised or down-graded. Surely the first rule of science is to describe what you see. Informed and self-critical clinical experience is the cornerstone of all that we do, and should be harnessed.

Unlike most other health specialties, palliative medicine does not have its own unique basic scientific grounding, methodology or technology. It offers instead specialist practitioners and teams with unique attitudeknowledge- skill mixes designed to meet the needs and wishes of their clients. These services are in a unique position to assist in the conduct of research and may have valuable ideas for projects, but they are often poorly equipped to conduct research themselves, and this expertise usually has to be brought in.

Most services have little time or aptitude for research but there are increasing pressures upon them to engage in it. Given the parlous state of the workforce in Australia and other countries, over-ambitious research expectations can be burdensome and often fail to deliver useful results.

The study of palliative care requires collaborative inputs from diverse disciplines and methodologies, depending on the question being asked, a fact that the most productive and successful research groups realised a long time ago. Everyone agrees that research collaborations are the way to go. However, they have to answer relevant questions, with realistic methodologies and time-lines and the resources have to be present at the service. level to do the work.

Most importantly, all practitioners and services should ask whether they audit their results, read widely and record their own experiences. A culture of healthy self-criticism and openness to new ideas is essential to the growth of any credible specialty. Furthering of local and global knowledge is everyone's business and not the preserve of a research elite, but not everyone can or should do their own research. Services will join in, if they have the resources to do so and the study is seen to be relevant. This is the challenge.