“That which can be asserted without evidence can be dismissed without evidence” – Christopher Hitchens
Sherlock Holmes, Hercule Poirot and Byomkesh Bakshi. Three great fictitious detectives gave us hours of on-the-edge reading with one single-minded task- the quest for evidence. The word ‘evidence’ is derived from Latin (evident= obvious to the eye or mind). Webster defines it as ‘a sign which shows that something exists or is true’. The Cambridge English Dictionary says that evidence is ‘one or more reasons for believing that something is or is not true’. Wikipedia says ‘evidence is anything presented in support of an assertion’.
Scientific evidence is based on experiments and observation. In the field of medicine, research is used to prove or disprove anything ranging from inheritance of disease, the value of any diagnostic tool and the effect and side effects of therapeutic measures. Clinical trials are research studies that explore whether a medical strategy, treatment, or device is safe and effective for humans. ‘Evidence based medicine’ helps us sift and sieve through numerous assumptions regarding etiopathogenesis, signs and symptoms, diagnoses and treatment of disease.
Cosmetic Dermatology is a scientific field that has branched out of mainstream dermatology and plastic surgery, and although it caters to ‘looking good’, it remains a medical specialty, practised as an art by persons of science. We carry out treatments of specific medically defined conditions. Often, these treatments are carried out not because of necessity, but because of want. Our pledge of ‘do no harm’ is more relevant than ever as there is a chance of permanent damage occurring not because of disease, but by therapy. At a time when procedures are routinely done in settings of ‘beauty parlours’ and ‘spas’ by non medical persons, the general public can be easily misguided, or worse, suffer grievous injury at the hands of unqualified people. Worse, there are few regulations regarding qualifications required for performing non surgical procedures and any Tom, Dick and Harry wants to practice ‘Cosmetology’.
Dr. C L Goh’s article titled “The Need for Evidence-Based Aesthetic Dermatology Practice” in the Journal of Cutaneous and Aesthetic Surgery has highlighted some very relevant points about the rise of aesthetic dermatology and why it is the responsibility of us, the medical practitioners, to provide scientifically sound and safe treatments to our patients. Five steps of practicing evidence-based dermatology are described as follows:
- Asking an answerable structured question generated from a patient encounter
- Searching for valid external evidence
- Critically appraising the evidence for relevance and validity based on hierarchy of strength in descending order, namely
- Systematic reviews and meta-analyses of randomized controlled trials
- Randomized controlled trials
- Nonrandomized intervention studies
- Observational studies
- Non-experimental studies
- Expert opinion
- Applying the results of that appraisal of evidence back to the patient
- Recording the information for the future
Two filters need to be applied if one is to keep practicing EBM: The first is to discard irrelevant information, and the second is to spend more time looking at a few high-quality papers, as per the concept of hierarchy of evidence.
Any concept backed by research is immediately acceptable to scientific mind. Evidence of safety and efficacy lends credibility to treatments and gives us the confidence to propose the same to our patients.
What about the source of evidence? Where do we look for evidence? There are grading and ranking systems and lists which are quite helpful, but often these are unable to keep up with the pace of new therapies constantly bombarding the market. We have reliable reviews, painstakingly gathered over many years from a large database like the Cochrane review. Here lies the catch. The review for photoepilation concluded that “some treatments lead to temporary short-term hair removal.High quality research is needed on the effect of laser and photoepilation”. Now here you have a result that doesn’t say ‘yes’ or ‘no’, while you have an OPD full of patients specifically seeking
laser hair reduction. It would be silly to stop offering them the treatment while we wait for further evidence. This is when articles, case studies and clinical trials published in peer reviewed journals, personal observations and observations shared by colleagues in conferences and CMEs can help us.
One need not go all out looking for evidence generated elsewhere. Just like while buying a new instrument, we check out the efficacy by comparing two machines from different companies on willing patients, we can gather our own evidence. It helps immensely to click good quality photographs of patients before and after treatment. One could make folders for different treatments used for the same condition and visually compare the results. No fancy data collection or analysis is needed for this photographic evidence. However, it is paramount that pictures are clicked under standard and consistent conditions with regards to light and position. Patients’ subjective feedback is equally important, as they are not only rating the results, but the entire experience from diagnosis to treatment and after. One happy patient will refer more, and this is an indirect evidence that what you did worked! With experience, most doctors develop a sort of ‘gut feeling’, or a ‘hunch’ about the treatments they routinely provide. There are no studies to support this and it is often inexplicable, yet following this feeling can give some of the most gratifying results. It can also help find novel applications for old treatments. Medico-legally speaking, in case things go wrong, it helps your case if you can prove that the treatment provided is proven and tested and not some experiment on your part.
Evidence based cosmestic practice- is it possible? Definitely! You may read, scour the internet, click pictures, talk with colleagues, get feedback from your patients and most important, keep the grey cells working.
Is evidence based practice needed? Absolutely! Apart from the medico-legal aspect, if you have enough evidence to convince yourself, convincing the patient will be a cakewalk. This scientific approach is what differentiates you from all the other salon, spa, herbal etc. cosmetic treatment providers.
“A wise man proportions his belief to evidence”. -David Hume
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