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Application of a medicolegal approach in clinical stalemates
  1. Michael Tang
  1. Correspondence to Michael Tang, Yale School of Public Health, Yale University, 60 College Street, New Haven, CT 06520-8034, USA; michael.tang{at}yale.edu

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Clinical equipoise, defined as the state of affairs when there is insufficient data to support one treatment over another, has recently been very much discussed and analysed. One particularly contentious issue is the usage of tissue plasminogen activator (tPA) in incidences of acute ischaemic stroke (AIS), where, as many as 40% of US emergency physicians refused to apply tPA despite the treatment being classified as a Class I recommendation in the American Heart Association (AHA) guideline.1–2 These reasons may include personal preference, reluctance to change or perhaps omission bias.3–4 This has led to Ubel's advent of the concept ‘behavioural equipoise’. Behavioural equipoise is defined as when physicians do not concur on a particular issue despite significant findings from clinical trials. Therefore, the scientific community enters into a state of stalemate. Debates can be found among neurologists and emergency room (ER) physicians all over the world, especially in Europe, the USA and Asia.5–9

Ubel argues that in a state of behavioural equipoise, further trials may be warranted. If doctors are not leveraging the therapy, then patients will not receive the best treatment. However, at least half the people will …

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