Dr. Archie Cochrane: Pioneer of Evidence-Based Medicine

Dr. Archie Cochrane: A Guiding Light in Epidemiology and Evidence-Based Medicine

In this article, we bring to you the journey of Dr. Archibald L. Cochrane, popularly known as Dr. Archie Cochrane. Dr. Archie Cochrane was a Scottish/British physician and epidemiologist. Dr. Archie Cochrane is best known for advancing the science of epidemiology and rallying behind epidemiological studies like randomized controlled trials and cohort studies, which are the pillars of evidence-based medicine. 

For his contributions to the science of epidemiology and evidence-based medicine, Dr. Cochrane is often credited as one of the fathers of evidence-based medicine, along with Dr. David Sackett from Canada and Dr. Alvan Feinstein from the United States who also made seminal contributions to advancing evidence-based medicine.

Dr. Archibald Leman Cochrane
Dr. Archiebald Leman Cochrane
Image Credit: Cardiff University Library, Cochrane Archive, University Hospital Llandough

Qualifications and Early Life of Dr. Archie Cochrane

Dr. Cochrane had a truly unconventional medical career from the very beginning. His medical education that started in 1931 had several interruptions, some of which were due to his illnesses, while others were of his own making when he chose to volunteer in the areas affected by the Spanish Civil War. He finally graduated from medical school in 1938. 

Dr. Cochrane had another close encounter with the war in his early career. He was serving as a captain in the Royal Army when he was imprisoned by the Germans during the second world war. He later continued his medical practice serving as a prisoner of war in the German-occupied areas between 1941 and 1945. It was there – right in the middle of the second world war – that he did his first amateur clinical trial on other inmates. 

Dr. Cochrane later received military honors (MBE) from the Royal Army for rendering his services to the prisoners of war. This also led him to land up with a Rockefeller Fellowship in preventive medicine. Realizing the limitations of curative medicine, he had developed a keen interest in preventive medicine. This fellowship exposed him to some of the best public health academic institutes of his time, namely the London School of Hygiene and Tropical Medicine in the UK and the Henry Phipps Clinic in the US, which is associated with the John Hopkins University. 

During his stay at the LSHTM, while studying for his diploma in public health, he was heavily influenced by Dr. Autin Hill, a pioneer in medical statistics and randomized clinical trials. This was a major influence that remained with him throughout his life as he advocated the use of RCTs to evaluate the utility of clinical and healthcare interventions through the prism of the RCTs and other epidemiological studies.   

Professional Career of Dr. Archie Cochrane

After specializing in public health preventive medicine, and epidemiology, Dr. Cochrane worked with the Medical Research Council for almost a decade. He was attached to the pneumoconiosis research unit and investigated the medical conditions of the coal workers, which laid the foundation of his academic career. He was then appointed as a Professor at the then Welsh Medical School, now Cardiff University Medical School. Cardiff University Medical School continues to celebrate the legacy of Dr. Cochrane through various initiatives.

After almost a decade, he was promoted as the Director of the Epidemiology Reserach Unit of the Medical Research Council. It was during his tenure as the Director of the Epidemiology Unit of the MRC that Dr. Cochrane produced nearly all of his seminal works. He also instilled the culture of conducting RCTs at this unit for medical, surgical, and public health interventions, which was taken to far greater heights by his successors. 

Recognizing his contributions, he was selected as the first President of the Faculty of Community Medicine. He also received several international fellowships and honorary doctorates from reputed institutions from across the world. 

Seminal Works of Dr. Archie Cochrane

Validation of Screening Procedures can be considered as the first seminal work of Dr. Cochrane that received widespread recognition. In this paper, he proposed that not all screening tests should be routinely advocated. He categorized the then available screening tests into three groups based on the medical and economic evidence for their routine use: Acceptable; Limited use, and Unacceptable. This analysis based on the medical and economic efficiency and effectiveness of individual tests introduced a new and never-ending debate into the utility of the specific health care interventions in the publically financed healthcare systems. This objective view of medical interventions later shaped the movement of Evidence-Based Medicine.    

Based on the success of his paper on the validation of medical screening, Dr. Cochrane was commissioned by the Nuffield Trust to write his reflections on the performance of the UK's National Health Service. The output of this Fellowship is known as Effectiveness and Efficiency: Random Reflections on Health Services. This book focuses on the role of RCTs in public health and medicine and the concepts of efficiency and effectiveness. This book remains a seminal and landmark work for the learners of public health worldwide. 

Another landmark work of Dr. Cochrane is a paper entitled Health service 'input' and mortality 'output' in developed countries. This paper examined the effect of health care resources on mortality in industrialized nations. This paper raised important questions about the inefficient allocation of medical resources in the US. This is still relevant and a must-read for all students of public health. 

Another extremely important work of Dr. Cochrane, though less popular as compared to the rest of his works, is the long-term cohort study of the Rhondda Fach cohort of coal mine workers. The Rhondda Fach cohort study investigated the cause of progressive fibrosis in the coal workers for over 30 years. This was one of the first projects of Dr. Cochrane during his employment with the Medical Research Council. Although he is unequivocally associated with popularizing and emphasizing the RCTs, he understood their limitations very well and was thus very fond of cohort studies spanning decades, which can be considered the second-best epidemiological evidence after the RCTs.     

One Man's Medicine: An Autobiography of Professor Archie Cochrane is a self-authored biography by Dr. Cochrane. This biographical work is still being published by Cardiff University and is available on their website along with many other useful resources penned by Dr. Cochrane.  

Dr. Archie Cochrane's Influence on Evidence-Based Medicine

Evidence-based medicine might have never gained the momentum that it could achieve if it was not for legendary epidemiologists like Dr. Archie Cochrane. In recognition of his contributions, Dr. Cochrane has been often credited as the Father of Evidence-Based Medicine. 

Cochrane Trust, which is the leading and largest organization behind the advancement of the evidence-based medicine movement has been formed in his name and is proud to be associated with his name. The Cochrane Trust and Library have taken the next steps recommended by Dr. Archi Cochrane and advocated the use of rigorous systematic reviews and meta-analyses (Cochrane Reviews) to guide the selection of efficient and effective treatments by clinicians and policy-makers.   

Dr. Cochrane received a CBE honor from the British Government for his pioneering contributions to the fields of medicine, epidemiology, and public health. He remains an unmatched inspiration for countless learners of public health and medicine worldwide. 

Selected Quotes from Dr. Archie Cochrane's Works 

Dr. Cochrane's writings clearly reflected his thoughts. Excellent clarity is the first trait that can be recognized in all of his works. Dr. Cochrane's works have another common trait of readability, which is a rarity in academic writing. If I would state that his writings are as simple as novels targeting high school children, it would not be an understatement. Here, I present to you a few quotes from his works to show you his excellent writing skills as well as the strength of his character.  

An excerpt from his seminal work on medical screening (Validation of Screening Procedures, 1971).
We believe there is an ethical difference between everyday medical practice and screening. If a patient asks a medical practitioner for help, the doctor does the best he can. He is not responsible for defects in medical knowledge. If, however, the practitioner initiates screening procedures he is in a very different situation. He should, in our view, have conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened.

Excerpts from his seminal work on NHS (Effectiveness and Efficiency: Random Reflections on Health Services, 1972)

I felt in this book I may have been too critical of my colleagues for whom I actually have the greatest admiration and affection........... What other profession encourages publications about its error, and experimental investigations into the effects of their actions?

This is my first, and probably, my last book, although I have published the usual number of scientific papers. In these, I would like to think I have made some contributions to the reduction of bias in medical measurements.

I once asked a worker at crematorium, who had a curiously contented look on his face, what he found so satisfying about his work. He replied that what fascinated him was the way in which so much went in and so little came out. I thought of advising him to get a job in the NHS, it might have increased his job satisfaction but decided against it.

It appears in general, it is Catholicism, Communism, and underdevelopment that appear to be against RCTs. In underdeveloped countries, it can be understood, but what have Communism and Catholicism against RCTs? 

Excerpts from his seminal work on the association between health care and mortality in industrialized countries (Health service 'input' and mortality 'output' in developed countries)

We believe that the results outlined in the next section are both interesting and amusing, and we make no apology for the necessarily subjective nature of some stages in our analysis.

We think that there are so many possible sources of error in this sort of data, and so many pitfalls in interpretation, that a slavish adherence to significance testing, if relevant, would give our results a spurious and perhaps misleading aura of precision. 

We do not claim that any of the associations are causal, although in one or two cases this hypothesis is attractive.

In general, however, we must admit defeat and leave it to others to extricate doctors from their unhappy position.

We believe that one overall conclusion may be drawn from this study. It is that health service factors are relatively unimportant in explaining the differences in mortality between our 18 developed countries. 

References and Suggested Reading

About the author

Dr. Naval Asija is a licensed MBBS Physician from India. MBBS is the equivalent of the MD degree offered by international medical schools. He is based in Delhi, India, and works as a medical writer, editor, and consultant. He supports medical researchers as an author's editor, medical communication companies involved in medico-marketing activities, and medical technology companies in improving their products. He can be contacted via his LinkedIn Profile: https://www.linkedin.com/in/navalasija/

Journey of a non clinical doctor


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