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The power of one

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A core value of clinical medicine is to do the very best for every single patient. But the principles of evidence-based practice involve developing a management plan that is informed by studies showing the net result of an intervention is balanced towards benefit. Accordingly, some patients will be helped by it, some will experience a null effect, and others will be harmed. How can we reconcile this with the practitioner’s focus on each individual patient’s interests? This question, though not novel, is implicit in many clinical decisions but is rarely articulated.

A current prominent example is the contention over whether to screen men for prostate cancer. Several articles in this issue revisit this question. Martin and colleagues’ analysis (doi: 10.5694/mja12.11597) concludes that prostate-specific antigen screening is likely to only be cost-effective in the < 1% of men classified as very high risk. While this is valuable information, it begs the question of how to identify these high-risk men. From a purely clinical perspective, the balance between the benefits and harms of prostate cancer screening remains unresolved, despite recent large studies, because of disagreement about how to interpret the evidence, say Del Mar and colleagues…