Tara Lamont: On failing well—Archie Cochrane’s legacy

Tara_Lamont_3I have been reading Archie Cochrane’s account of his life and work (not in general print, but I got it from the Cardiff University archives for £14.99). It is not at all what I expected. Although there are elements of autobiography in the classic, seminal monograph Effectiveness and Efficiency, these are anchored to the main, compelling argument for evidence based medicine. There, famously, he recounts his experience as a doctor in prisoner of war camps where, to his surprise, the lack of available treatment did not equate to bad outcomes. He concluded that not enough was known about what worked, leading to “Archie’s law” (as I have coined it), which is to “always assume that a treatment is ineffective unless there is evidence to the contrary.”

What surprised me in the memoir though, is the tone of it—honest (to the point of painful), spiky, and personal. It contains the unvarnished account of frustrations, such as taking six years longer than standard to qualify as a doctor. This was owing to not only a diversion to join the international brigade in the Spanish Civil War (what a generation), but also an abandoned PhD, and some years spent following his Jewish psychoanalyst in exile across pre-war Europe. He is candid about some of the personal problems that led him to seek this help, and which thwarted, it appeared, his adult relations. He attributes some of these difficulties to his early years with a distant, Calvinist upper class family.

His frustrations were not only personal though. This book also charts his work after the war in running a pioneer epidemiology unit in Wales. In one of his chapters he talks about a “decade of failures” in his “two valley research” here, which never quite achieved what he imagined in understanding the aetiology of pneumoconosis. He also expresses a feeling of shame for his long stints as sole medical officer at a series of prisoner of war camps —wondering if he in some ways bypassed the “real war” or the glittering medical career of his contemporaries. Indeed, his account of his wartime experiences focuses on sorting out food parcels and digging latrines. Another kind of heroism.

The tone throughout is humane, self-searching, and challenging —of himself as well as others. He saw himself as outside the establishment. A brilliant story that gives you the measure of the man is in his evaluation of some new coronary care units. A trial was set up comparing these with care at home; although the cardiologists were loath to subject such self evidently effective treatment to this kind of scrutiny. As Cochrane says (p 211):

“The results at that stage showed a slight numerical advantage for those who had been treated at home. It was of course completely insignificant statistically. I rather wickedly compiled two reports, one reversing the numbers of deaths on the two sides of the trial. As we were going into committee, in the anteroom, I showed some cardiologists the results. They were vociferous in their abuse: `Archie’, they said, `we always thought you were unethical. You must stop the trial at once…’ I let them have their say for some time and then apologised and gave them the true results, challenging them to say, as vehemently, that coronary care units should be stopped immediately. There was dead silence and I felt rather sick because they were, after all, my medical colleagues.”

So, not a clubbable man then. Even a colleague he respects is described as “overweight . . . rude, bad tempered.” This impatience with colleagues, combined with a deep empathy for patients (from the Russian tubercular prisoner dying in his arms in one camp, to the rather cranky distant cousin for whom he tenderly cares at home) shines through on every page. Although never married, he created a wonderful home and garden that became a refuge for many—including the rather cranky distant cousin and companion who were cared for by him to the end. There is something about his unconventional, but far from solipsistic life. Along with his unwavering commitment to scientific method (to the comic extent of tracking down all family members at a funeral for faecal samples in tracing a hereditary disease), and his frustration with the rituals and norms of medical practice, these are all a part of his greatness and his ability to shape medical science. His chequered life story and struggles had as much of a part to play as his undoubted intellectual vigour and vision.

This chimed with another great life of medicine that I was thinking about—Cicely Saunders. I haven’t read her letters or biography, but from The BMJ’s short profile, I was struck by parallels with Archie Cochrane. Born to a privileged but cold and distant family, plagued by chronic back pain, finding affinity with the marginalised (including a thread of significant Polish men), and quietly defying convention by living in shared housing with friends even after marriage. Hers was a protracted path to qualified doctor—via social work (hospital almoner) and nursing. She struggled for acceptance at a time when social and professional expectations were narrow. And yet, it is because, not despite, of these tensions that her pioneering vision of palliative care—and her understanding of “total pain”—was born.

I was thinking of this as the pressure seems even greater now for our teenage children to make directed choices, and compile mini dossiers of activity and unblemished achievement even before they reach college. What place is there for those who (like Archie) need time to stumble, and struggle, and try many paths before finding work where they can make a difference?

Tara Lamont has worked for over 20 years in health services research, audit, and patient safety. She currently works for the National Institute for Health Research and is an honorary fellow at the University of Warwick, but blogs in a personal capacity.

Competing interests: The author has no competing interests to declare.