Outside the Box: why are Cochrane reviews so boring?

Trish Greenhalgh asks why Cochrane reviews are so boring.¹ Strange that she should ask such a question on this particular platform. Many colleagues ask me the same question about the BJGP (identified as I am as the local RCGP stooge because of my varied faculty activities during the course of my career). My answer in both contexts is the same: of course they are boring to practitioners because the job of practitioners is (no surprises) to practice. Both Cochrane reviews and the research articles appearing in the BJGP, nevertheless, are essential to the progress of practical medicine. We turn to them when we need them.

To answer another question, I have read Cochrane reviews. Let me give the most recent occasion because the narrative illuminates the synergy between trial evidence and complex decisions. Faced with high rates of referral and surgery for carpal tunnel syndrome, our commissioning consortium sought to explore the alternatives. Many issues had to be taken into consideration: the influence of local expert opinion, secondary-care behaviour in the market, GPs’ knowledge of the condition, whether GPs possess the skills for injection and last, but not least, whether splints and injections are effective and safe. My interpretation of the Cochrane reviews on the subject was that the evidence for the effectiveness of non-surgical interventions is weak. But they are safe. So what to do? In this complex situation, the decision to offer non-surgical intervention first line (with safety provisos for those with advanced disease) is sensible. Had the evidence been that non-surgical interventions only delayed surgery or were useless, such a decision would not have been sensible. The evidence was only one part, but a vital one, in the decision.

I do not find Greenhalgh’s suggestion of a database of opinions and ideas at all ‘outrageous’ or even radical. It already exists, it is called the World Wide Web. You can use your favourite search engine to find opinions and ideas on many health matters. I guarantee that some of them will be outrageous.