Commentary: The need for clinical freedom

better investigated than almost any treatment for any cardiovascular problem this treatment has not yet become part of routine clinical practice – because many doctors prefer to move on to the new and unproved, which they hope will have dramatic effects, rather than to assimilate the relatively small benefits that are available from tested treatments. The end of clinical freedom means that clinical trials and research in general have become more rather than less important, and when resources are scarce a greater proportion of them must be channelled into evaluation. If investigation and treatment are to be limited we must know which investigations and which treatments are valuable and which are not. New high cost investigational facilities (such as computed tomography a few years ago, or nuclear magnetic resonance scanning today) should be installed only in institutions able to evaluate them properly and with catchment areas adequate to provide the sort of patients to whom the new techniques will be applied when they become available to the average district general hospital. No new treatment (for example , coronary artery bypass grafting in patients without symptoms) should be allowed except as part of a properly conducted clinical trial, and such a trial would have to be conducted on a multicentre basis so that a wide variety of patients and medical skill would be included. Before they can be approved for prescription on a large scale new drugs need to be tested not only for efficacy but also in comparison with old drugs; a new and expensive drug can be accepted only if it is superior to an older and cheaper one. Training in evaluation techniques must form part of the education of any potential consultant; only by so doing will consultants carry through their career the habit of inquiry and scepticism that will be essential in the more restricted financial atmosphere that lies ahead. Clinical freedom died accidentally, crushed between the rising cost of new forms of investigation and treatment and the financial limits inevitable in an economy that cannot expand indefinitely. Clinical freedom should, however, have been strangled long ago, for at best it was a cloak for ignorance and at worst an excuse for quackery. Clinical freedom was a myth that prevented true advance. We must welcome its demise, and seize the opportunities now laid out before us. Oral mexile-tine in high-risk patients after myocardial infarction. trial comparing oxprenolol …