Heroes and evidence.

See associated article on page 20. E very thoracic surgeon should know about Archie Cochrane. He is as close to a true hero as a physician can get, but I am sure there are those who see him as the devil incarnate. As is apparent from some of the highlights of his career (Table 1), he lived during an exciting time. In the 1930s Professor Cochrane was branded as a “Trotskyite” because he advocated a national health system for Great Britain. His advocacy was tempered by 4 years being held in multiple German prisoner of war camps. He saw soldiers die of tuberculosis and he was never sure what the best treatment was. Believe it or not, he did have some alternate therapies to offer the soldiers in the prisoner of war camps. He could choose between collapse therapy, bed rest, supplemental nutrition, or even high-dose vitamin therapy. A quote from his book1 sums up his frustration: “I had considerable freedom of clinical choice of therapy: my trouble was that I did not know which to use and when. I would gladly have sacrificed my freedom for a little knowledge.” After the war he continued to lobby for a national health service, and the National Health Service was created in the early 1950s. His experience with the uncertainty about the best treatment for tuberculosis and other chest diseases continued after the war, when he became a researcher in pulmonary disease for the Medical Research Council in Great Britain. In the late 1940s and early 1950s, drug therapy for tuberculosis was introduced and there were even some randomized clinical trials that addressed the issue of the best therapy for tuberculosis. With some encouragement from his friends, Archie embarked on a career that would now be called medical epidemiology and health planning. Still with an interest in tuberculosis, now heightened by the fact that he had contracted the disease, Archie wanted to know the best drug therapy for tuberculosis. There were now drugs available that could treat this disease, streptomycin being the first really effective drug against Mycobacterium tuberculosis.2 He was a patron of randomized controlled trials (or RCTs, as he liked to refer to them) to test important medical hypotheses. He used the evidence gained from these RCTs to make decisions about the best therapy on the basis of available evidence—the beginning of “evidence-based” practice. He believed that RCTs are the best form of evidence to support medical decision making (so-called “class 1” evidence). Initially he was a voice in the wilderness, but this changed little by little. In 1979 he criticized the medical profession for not having a critical summary, organized by specialty and updated periodically, of relevant RCTs. In the 1980s, a perinatal database of important RCTs was developed at Oxford. In 1987, the year before Cochrane died, he referred to a systematic review of RCTs of care during pregnancy and childbirth as “a real milestone in the history of randomized trials and in the evaluation of care,” and he suggested that other specialties should copy the methods used. This led to the opening of the first Cochrane center (in Oxford, United Kingdom) in 1992 and the founding of The Cochrane Collaboration in 1993. Now the Cochrane Collaboration is a repository of RCTs, both disease-specific and specialty-specific. Clinicians and lay persons can go to the Cochrane Web site (http://www.cochrane.org/) and find summaries of all available RCTs on a wide range of medical subjects. From the above discussion, I think it is fair to call Archie Cochrane the “father of evidence-based medicine.” Only one of the thousands of summaries of RCTs found on the Cochrane Collaboration Web site has anything to do with any element of cardiopulmonary bypass (CPB). The Cochrane Heart Group reviewed the evidence that hypothermia reduces stroke after coronary artery bypass grafting performed with CPB. In this issue of the Journal, Bartels Tyler Gill Professor and Chief, Division of Cardiothoracic Surgery, University of Kentucky Chandler Medical Center, C208, 800 Rose St, Lexington, KY 40536-0084 (Email vferr2@uky.edu).