As we write this editorial and as you read it, we should all reflect on how every one of us is involved in decisions about health and social care, as users, providers or payers. But, how do we know that the information we use to inform our decisions about what to do, take, offer or buy is based on reliable, robust and trustworthy evidence, in which biases have been minimised? This challenge of recognising and minimising biases has faced those doing and using the research needed to generate the evidence for millennia. In recent decades, with the advent of concepts such as evidence-based medicine, the challenge has come more to the fore but it has a long history. This history is important if we are to learn from successes and failures of the past, and if we are to gain a better understanding of why things are carried out in certain ways and to give credit where it is due. It provides a foundation for understanding why and how ‘fair tests’ are needed to assess the effects of treatments. Against this background, we are proud to announce a renewed partnership between the Royal College of Physicians of Edinburgh and the James Lind Library (JLL) to help bring this history to a wide audience. The JLL (https://www.jameslindlibrary.org/) uses material from history to illustrate principles underlying fair tests and how these have developed and been applied over time, showing how these relate to the interests of patients, practitioners and policy makers in the twenty-first century.
In 1998, the Royal College of Physicians of Edinburgh launched a website called Controlled Trials from History. This marked the fiftieth anniversary of the publication of the Medical Research Council’s randomised trial of streptomycin for pulmonary tuberculosis.1 The website provided a focal point for a collection of material on how, over many centuries, controlled trials had attempted to minimise bias when seeking to identify the true effects of treatments. This included James Lind’s iconic work testing various possible treatments for scurvy and, on the two hundred and fiftieth anniversary of the publication of his Treatise of the Scurvy,2 Controlled Trials from History was redesigned and relaunched by the College as the JLL in 2003.3 By 2011, the growth of the JLL had become so substantial that Sir Iain Chalmers, its Editor-in-Chief, sought and obtained permission from the National Institute for Health Research (NIHR) to host it within a broad, NIHR-funded work programme called the James Lind Initiative.4 A redesigned JLL was launched on International Clinical Trials Day 2015 and continues as the current website. The design and content takes account of the Testing Treatments interactive website, which explains the need for and characteristics of fair tests for lay audiences.5 When the James Lind Initiative ended with Chalmers’s retirement earlier this year, the College agreed to resume its role as the host of the JLL.
The JLL is organised around three main types of material: explanatory essays, records and articles. The explanatory essays seek to promote wider understanding of why fair tests are needed, and what they have come to consist of. The essays cover a wide range of the biases that can distort the findings of research into the effects of treatments, which, if not reduced, would limit the ability of any test to be truly fair. This collection of essays has now been brought together in the new book, The James Lind Library’s Introduction to Fair Tests of Treatments, and an important early step in our renewed partnership is that the full content of the book is freely available as a supplement to this editorial (www.rcpe.ac.uk/jrcpe).
There are more than 1,100 records in the JLL, which include scans of key passages from pivotal articles and documents, often with links to full text, portraits and other material. These illustrate the development of fair tests of treatments over two millennia and, once a particular method has become widely accepted into practice, records are no longer added.
The more than 250 original articles published in the JLL include brief histories on the evolution of measures to reduce biases and the play of chance, commentaries contextualising some of the records, biographical sketches and personal reflections. In coming years, some future articles, in particular those on controlling bias in studies of precision, individualised or targeted medicine may be published in the Journal of the Royal College of Physicians of Edinburgh (JRCPE) as peer reviewed articles.
In recent years, the focus of the JLL has broadened beyond its initial emphasis on the history of how biases and random errors have been controlled in fair tests of treatments. It now increasingly includes material about how research evidence can serve patients more effectively. This includes the addition of records and articles for key milestones and developments in areas such as research synthesis, summaries and appraisal of evidence, and the presentation of evidence to the public. We anticipate continued growth in these areas and even greater use of the JLL as a learning resource for students. In a one-question survey last year, more than 600 users responded, revealing that 43% were students; with a further one-third identifying themselves as health professionals or researchers.4 Links to the JLL are also being embedded in other learning resources, such as the Centre for Evidence-Based Medicine’s Catalogue of Bias (www.catalogofbias.org).
We look forward to the new fruits of the partnership between the College and the JLL. We will continue to build on the work of Sir Iain Chalmers and Patricia Atkinson, the JLL’s administrator, and we are pleased that both will be continuing as integral parts of its editorial team. We hope to guide you and users of the JLL to an increasing body and variety of material on how and why the design, conduct, reporting and use of fair tests of treatment have developed over time. We hope that this will help us all to recognise how these fair tests are vital to well-informed decision-making about health and social care in the twenty-first century.
Acknowledgement
The editorial board of the JRCPE wishes to acknowledge that the contents of the JLL supplement (available at the JRCPE website: www.rcpe.ac.uk/jrcpe) have not been formally peer reviewed by the JRCPE.
References
1 Medical Research Council. Streptomycin treatment of pulmonary tuberculosis: a Medical Research Council investigation. Br Med J 1948; 2: 769–82.
2 Lind J. A treatise of the scurvy. In three parts. Containing an inquiry into the nature, causes and cure, of that disease. Together with a critical and chronological view of what has been published on the subject. Edinburgh: Sands, Murray and Cochran for A Kincaid and A Donaldson; 1753.
3 Chalmers I, Milne I, Tröhler U et al. The James Lind Library: explaining and illustrating the evolution of fair tests of medical treatments. J R Coll Physicians Edinb 2008; 38: 259–64.
4 Chalmers I, Atkinson P, Badenoch D et al. The James Lind Initiative: books, websites and databases to promote critical thinking about treatment claims, 2003 to 2018. Res Involv Engagem 2019; 5: 6.
5 Chen Y, Chalmers I; TTi editorial Alliance. Testing treatments interactive (TTi): helping to equip the public to promote better research for better health care. J Evid Based Med 2015; 8: 98–102.
