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Clinical Epidemiology:
An Introduction
It’s a normal day in the clinic. A patient who’s been referred to you enters the office, you listen
to him as he begins to explain his problem, and you take his history in the process. The patient
is a 70 year old man, with clear signs of fatigue. He has a history of smoking and was previously
diagnosed with mild COPD. He’s previously been prescribed short–acting bronchodilators to be
used when needed. Your patient explains that for the last few weeks he’s felt increasingly out
of breath, for example after climbing the stairs. At night a cough has been troubling him,
disturbing his sleep.

Given this information, you’re faced with a set of decisions to make. What’s the patient’s
diagnosis? Is this an exacerbation of his COPD or an alterative diagnosis? How certain are you
about the diagnosis? Will the patient require further testing to confirm your suspicions or to
rule out other possibilities? And if you decide to carry out further testing, how will this affect
your patient? If the tests are expensive or invasive, will the benefits of testing outweigh the
burden?

The uncertainty does not rest here. Even when you‘ve reached a diagnosis, it might not be clear
how your patient’s health will progress, and whether any medical intervention will be necessary
to improve the patient’s prognosis. And even when treatment is indicated, there may be
several options. It may be that one of the available treatments is generally more effective than
the others but brings with it a greater risk of side effects. Selecting the best treatment for your
patient becomes yet another challenge.

When a patient enters a hospital with a set of complaints, we, the medical practitioners, have
to use information from the patient as well as our own knowledge to determine what the
patient’s problem is and how we should proceed in order to lead our patient towards a
favourable outcome. But what kind of information should we use to make decisions, and where
does this knowledge come from? Before we start applying our knowledge in practice, it’s
important to realise that not all of the information we have in front of us is useful for clinical
practice, and some kinds of information are more valuable than others.

One could base clinical decisions on a knowledge of disease mechanisms. If we understand how
a disease works, perhaps this can help us to inform and treat our patient. But this kind of
knowledge is often insufficient to answer complex medical problems, and it’s often not directly
relevant to the challenges of daily practice. Thinking back to our patient, a clear understanding
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of the underlying mechanisms of COPD cannot in itself help us reach a diagnosis or decide upon
a treatment plan.

Instead, traditionally, clinicians have used their own experiences as a basis for decision making.
It might be that you‘ve previously seen patients presenting with similar symptoms to our COPD
patient and you could base your decisions on the results of what you‘ve seen before. However,
this approach is problematic because our experiences are often limited, even if we’re experts
within a field, and therefore there’s the potential for our judgements to be both subjective and
biased. While we inevitably should use this kind of knowledge to make decisions for our
patients, we often face challenges that cannot be solved by experience alone.

Alternatively, we could base the judgements we make on evidence derived from clinical
research, and this approach is gaining increasing recognition as a major cornerstone for
decision making in daily clinical practice. Provided that the information from clinical research is
relevant and valid, an evidence-based approach will help to reach the most sound decisions.

It should be emphasized that in daily practice, clinicians will not only base their decisions on the
available scientific evidence pertaining to the problem at hand. In addition, they will use their
clinical expertise, as well as the preferences of patients. This is a complex process and
clinicians commonly come across situations where confidently making a judgement that
balances all of these factors can be difficult. If, in the example of the COPD patient introduced
in this lecture, the scientific evidence indicates that this patient should undergo additional
pulmonary function testing, your experience may tell you that, as in the past, this test will not
in all likelihood add any diagnostic information for this particular patient, while the patient
himself may tell you he’d really like to have the pulmonary test.

Where does scientific evidence come from? And what can we do if there isn’t any existing
evidence from research related to our problem? We could decide to generate more evidence
by designing and conducting a clinical epidemiological study. To do this, we generally collect
information from hundreds or sometimes even thousands of patients that we can then use to
synthesise new evidence in order to solve our clinical problem. While this may not help the
patient sitting in your clinic right now, it could help you and other clinicians to make decisions
for future patients.

Epidemiology has traditionally focussed on studying the causes of disease, and in recent years
there has been a transition towards clinically relevant research. In clinical epidemiology,
research always starts with a clinical problem that needs to be answered. It’s then the role of
the researcher to translate this problem into a question that can be studied using the methods
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and resources that are available. In the coming weeks, we’ll be focussing on this problem of
translation, which is really at the core of clinical epidemiology.