O que é evidência? Não evidência significa inexistência? Como podemos encontrar evidência? Quando podemos dizer que temos evidência? Estas são algumas perguntas e caminhos que tentaremos elucidar nesse texto para que todo iniciante possa fazer sua pesquisa.
Primeiramente vamos a questão chave da sua pesquisa a pergunta que não quer se calar, isso orientará o objetivo de seu trabalho. Segundo é a pesquisa bibliográfica que deverá fazer antes de começar a definir sua metodologia de trabalho para melhor entender do assunto.
Vamos tentar resumir essa experiência com a seguinte imagem. Como encontrar agulhas num palheiro? Você pode tentar separar as palhas até encontrá-las, mas isso certamente demoraria muito e dependendo do tamanho do palheiro pode ser uma tarefa impossível. Você então pode pegar uma pequena parte do palheiro para catar, mais isso não garante que existam agulhas naquele pedaço escolhido. Sendo assim vem a terceira questão, calcular o tamanho mínimo para a amostra. Quanto devemos pegar de palhas para que com um grau bem aproximado de certeza possamos dizer que ali devem ter agulhas. O conceito depende simplesmente do sucesso que estudos anteriores tiveram ao procurar agulhas preferencialmente ou qualquer outro objeto similar no palheiro. Estamos dizendo que o palheiro é a população e as agulhas são os resultados esperados.
Se nos atirássemos no palheiro conseguiríamos encontrar agulhas? Talvez, necessitamos de pesquisa para o óbvio? Não. Qual a garantia de que as picadas que sentiríamos seriam provenientes de agulhas? Poderia ser a própria palha? Isso não é evidência. Olhar as palhas e catar as agulhas resolveriam a questão? Será que todas elas são visíveis a olho nú? Isso nos coloca diante da escolha do instrumento. Poderíamos então recorrer a diferentes ferramentas para buscar evidência sobre a existência de agulhas. Sabendo, daí a importância de se conhecer o assunto, que as agulhas brilham sob a incidência da luz ou mesmo que poderiam ser atraídas por um grande imã, poderíamos capturá-las ou visualizá-las. Estamos falando agora de intervenções como a luz e o imã e de formas de mensuração como a visão e o magnetismo, intimamente ligadas ao objetivo e questão do estudo: existem agulhas dentre as palhas daquele celeiro?
Ao falarmos em celeiro incluímos uma parte da população de palhas que estão em determinado lugar com determinadas características. Poderíamos pegar qualquer palha ou entrar em qualquer celeiro? Ou devemos escolher aquele tipo em que seja mais fácil a identificação de agulhas? Obviamente que sim à segunda pergunta, poderíamos também excluir tipos de palhas e celeiros que podem esconder ou confundir a identificação de agulhas que de alguma forma interfeririam no resultado. Como por exemplo, aquelas que estão impregnados de outros metais ou vidro que possam ser identificados pela luz ou pelo imã como agulhas. Quanto maior a “pureza” da amostra melhor. Selecionar uma amostra sensível ao instrumento é dar poder ao estudo, através de critérios de inclusão celeiros om agulhas) e exclusão – retirarmos da amostra aquilo que possa influir negativamente no resultado. Pesquisar palhas no celeiro do vizinho que não possibilitam acesso à investigação, expõe a necessidade da ética e do consentimento livre e esclarecido. O caminho será sempre o mais fácil e simples, não o difícil. Uma pesquisa não abraça todas as questões e não dá prêmio Nobel a ninguém! Somente uma obra é capaz de conferir esse título.
Mas como usar essas ferramentas na identificação de agulhas? Mesmo escolhendo bem a amostra com os critérios acima, não podemos simplesmente sair por aí passando um imã no palheiro ou iluminá-lo e achar que tudo que espeta, captura ou brilha são agulhas. Simplesmente porque “as coisas ou são o que parecem ser, não são e nem parecem ser e mais ainda são e não parecem ser ou não são, mas parecem ser” (Epictetus, século II d.C.). Sendo assim para nos aproximarmos da verdade temos que fazer testes que contemplem essas 4 possibilidades de diagnóstico. Esta é uma das razões por que separamos nossos estudos sobre a amostra do palheiro em pelo menos 2 grupos X 2 resultados possíveis. Em um grupo interveríamos de modo a jogar a luz e palpar a palha na expectativa que as agulhas espetem ou brilhem e no outro grupo fingiríamos intervenção, na esperança que neste grupo observaríamos menos picadas ou brilhos que no primeiro. Fingir é importante, pois assim atribuiríamos o aparecimento das agulhas de fato as técnicas de iluminação ou magnetismo, passarmos a lanterna não iluminada sobre o palheiro, assim como um metal simulando o magnetismo é a garantia de que a luz e o magnetismo e não a lanterna ou o metal são responsáveis pela identificação de agulhas. Encontrar pontos brilhosos, outros metais ou mesmo picadas (no caso de usarmos a palpação das palhas) não seriam atribuídos à luz, ao magnetismo ou ao tato (à intervenção estudada) e no caso de inconsistência na observação de agulhas diríamos que o estudo teria uma baixa validade interna, a capacidade da aferição de agulhas pelo instrumento utilizado, os casos (agulhas) não são casos. Quanto maior a identificação dessas agulhas no grupo controle menor a diferença entre eles, sem evidência, pois não haverá uma diferença estatisticamente significante entre os grupos, o que não quer dizer que não existam. Estamos falando de estudos controlados onde um grupo é o controle (“intervenção fingida”), do outro, o grupo teste (intervenção estudada). Estamos falando também, no caso de não pensarmos em quem manuseará a lanterna ou o imã (devendo ser a mesma pessoa com a mesma técnica) que pode gerar um viés, um erro no desenho do estudo. Quando lidamos com variáveis não conhecidas e se influem no resultado chamamos de variável de confusão, pois não permitirá atribuir a luz ou ao magnetismo o efeito de se encontrar agulhas. A forma de lidarmos com essas variáveis é a aleatorização das amostras, um sorteio livre de influências que distribuiriam essas variáveis entre os grupos teste e controle. A luz ou o palpar da palha ou o imã poderia ser o medicamento homeopático. As agulhadas ou a capura delas podem ser um resultado positivo à saúde do paciente se diferente do grupo controle. E a lanterna de plástico (sem magnetismo) e com a luz desligada, o metal sem magnetismo ou até mesmo uma mão mecânica sem sensibilidade, o placebo.
Eis que surge uma nova questão. E se o pesquisador ou interventor ou as pessoas que medem o experimento estiverem muito desejosas de observarem resultados positivos e por isso, mesmo inconscientemente, escolhessem amostras de palhas mais reluzentes para o grupo teste (com a intervenção real), ou mesmo escolhessem palhas mais macias cuja sensação de espetar seria menos repetitiva no grupo controle (aquele em que fingimos a intervenção)? E se aqueles que medem os resultados ou fazem a pesquisa soubessem qual é o grupo teste e isso os influenciassem a notar mais brilhos ou espetadelas? Estamos falando aqui da necessidade das amostras de palha serem escolhida aleatoriamente e de estudos cegos onde todas as pessoas participantes não sabem qual é o grupo aonde há intervenção real. A aleatoridade na amostra define o que chamamos de estudo epidemiológico tipo ensaio clínico. Aqueles que não tem sua amostra aleatória chamamos de estudos tipo observacionais. Os ensaios clínicos são os únicos que de fato são capazes de mostrar evidências de que alguma intervenção funciona. Já os observacionais sinalizam características/ variáveis diferentes das amostras que mais propiciam a identificação ou o risco de encontrarmos agulhas. É óbvio também que assim como numa corrida de cavalos todos os grupos devem largar em condições idênticas (ou o mais próximo disso), com as mesmas chances de ganhar a prova, deixando a diferenciação apenas para as características dos animais, treinos ou cavalheiro, grupos homogênios. Logo numa pista de corrida, a distância a percorrer entre os concorrentes também deve ser igual, seguimento ou follow up. O acompanhamento de um tratamento também deve ser igual assim como o momento de aferição de resultados.
E quanto à pergunta de quando podemos dizer que há evidência? É simples notar que ao termos 2 grupos X 2 resultados possíveis: positivo e negativo sendo nossa hipótese verdadeira chegaríamos a equação oriunda de Epictetus (de 4 diagnósticos possíveis; 2 X 2 = 4) onde no grupo teste um resultado positivo representam coisas que são, no grupo controle um resultado negativo significa que as coisas não são parecendo ou não ser. Porém um resultado a priori duvidoso no grupo teste: as coisas são, mas não parecem ser e o mesmo no grupo controle um resultado negativo as coisas não são mas parecem ser, tem de ser contrapostos em ambos os grupos. Sendo assim se tivermos mais resultados positivos no grupo teste e mais resultados negativos no controle parecendo verdadeiros ou não, nos aproximamos mais da verdade de que existem agulhas no palheiro. E isso é evidência.
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