For many years, thoughtful commentators have highlighted the shortcomings of evidence-based medicine (EBM). Among them was Alvan Feinstein, one of the great pioneers and theoreticians of clinical research, and arguably one of the founders of the EBM movement.¹ But despite the increasing discontent with this mode of thinking, EBM remains an extremely prevalent intellectual vice that has captured the mindset of the medical community.
In the last few days, I came across some particularly striking examples of how EBM dominates the medical psyche.
First, a report from MedPage Today about “Giving Patients Evidence-Based Reassurance.” According to the author, the medical literature contains a number of studies and at least one systematic review to show us that educating patients and reassuring them is in fact reassuring. Phew! We now have empirical proof (and thus, reassurance) that our pats on the back are not going to waste! But a word of caution: apparently, the best way to reassure patients remains “murky.” More studies are needed…
On a related question, I was challenged on a statement I had made in my post against soda taxes.
@supermarioelia@shawn_whatley@michelaccad “good and long-lasting habits come through persuasion and education” Evidence 4 this statement?
— Yoni Freedhoff, MD (@YoniFreedhoff) August 8, 2015
I had anticipated that my article would elicit controversy, but it did not occur to me that that particular statement would be disputed on empirical grounds. What now? Should we conduct a clinical trial to show the benefits of persuasion and education?
Finally, in a Nature article discussing the reaction to a recent editorial by Steven Pinker, I was made aware that even research ethics review is subject to empirical examination. A systematic review in the journal PLOS looked at all the research done on research ethics reviews and found the field to be lacking. It lamented the absence of randomized trials about ethics procedures!
While EBM initially arose out of a desire to make more rigorous the way we evaluate therapies, it has expanded its reach to include under its purview all aspects of human behavior, and has turned into an empirical fundamentalism that harks back to the philosophy of Francis Bacon. Under this worldview, no opinion can be deemed valuable unless sanctioned by a clinical study, preferably a randomized controlled trial or systematic review. Since we now know empirically that clinical trial truths have half-lives measured in months or a few years at best, the persistence of EBM mania is testimony to the great intoxication it has produced.
EBM’s empirical fundamentalism is an intoxication of the intellect because it is an attack against reason. One is no longer allowed to deduce on the basis of established premises and principles, one must only induce from the observed “facts” or “evidence,” as if the evidence could speak for itself. Of Francis Bacon’s idea of radical empiricism, Murray Rothbard had this to say:
Echoing many other thinkers of past generations but putting it squarely and bluntly, Bacon divided all knowledge into two parts, divine and natural. Man’s knowledge of supernatural and spiritual matters came from divine revelation, and that was that. On the other hand, knowledge of material affairs, man and the world around him, was wholly empirical, inductive, arrived at through the senses. In neither case was there any room for human reason, that great conduit of knowledge lauded by classical philosophy from the Greeks to the scholastics. Knowledge of spiritual and divine matters was purely fideistic, the product of faith in divine revelation. Earthly knowledge was purely sensate and empirical; there was no room for reason there either.
Come to think of it, evidence-based mania is more than an intoxication. It is an intellectual amputation.
Notes:
1. See, for example, “Problems in the ‘evidence’ of ‘evidence-based medicine’” and “Meta-analysis: statistical alchemy for the 21st century,” which I blogged about previously. I have the utmost respect for Alvan Feinstein. I first discovered him as an intern when I came across his magnificent Clinical Epidemiology: The Architecture of Clinical Research
Dear Dr. Accad,
I am not a physician, but I am grateful to the physician friend who referred to one of your blog posts (can’t remember which) in a Facebook post. I took the bait and now write to tell you how intellectually stimulating I find many of your posts to be. As you surely know, you discuss specifically medical(-practice) issues in a way that acknowledges their many connections to human weal and woe far beyond medicine only. In particular, I am grateful for your advocating time and again what earlier thinkers called right reason, that of especially the pre-Cartesian variety that I think still corresponds more fully to the breadth and depth of this gift than most notions of rationality today.
I’m curious about your own faith: are you Catholic? The breadth of your knowledge of the humanities expressed in ways congruent with Christian faith prompt my question.
I am Pentecostal (worshiping among Methodists) and a professor of biblical studies working as a reference librarian at Oral Roberts University, Tulsa, OK.
Thank you for your public writings. I hope your views influence many.
Sincerely yours,
Mark E. Roberts, PhD
Thank you so much for your encouraging remarks, Mark. Yes, I am Catholic.
You correctly recognized that I do find inspiration in the pre-Cartesian notions of right reason, prudence, phronesis, practical wisdom, etc., going back to Aristotle. Indeed, few today are aware of the extent to which the modern concept of rationality is actually an impoverishment of the mind. I think (hope) that is changing, though, and I find that across many discipline (medicine, economics, science, law) there is a renewed interest or rediscovery of some useful old principles.
Keep in touch!
Michel
I am wary of an anti-EBM backlash. I think that few would argue that, in the absence of high-quality evidence to guide a clinical decision, a physician shouldn’t be guided by whatever evidence is available supplemented by common sense. At the same time, “common sense” has, in the course of my own medical career, been responsible for the following gross fallacies, which were only proven to be fallacies as a result of subsequently published evidence:
• Beta blockers are harmful in patients with heart failure
• Postmenopausal hormone replacement therapy reduces risk of coronary events in women
• Antiarrhythmics reduce adverse events in patients with cardiac dysrhythmias
• Proton pump inhibitors are completely safe (“these drugs have absolutely no risk associated with them”-Direct quote from a medical school lecture)
• Antibiotics are indicated for “acute bronchitis”
• Etc. etc. etc. One pillar of “common sense” that may be about to topple is that losing or gaining weight is purely a matter of calories in vs. calories out (from activity); Recent advances in understanding the role of the intestinal biome in the absorption of energy from food, and thus obesity, may bring that one crashing to the ground in the next few years.
There will never be enough researchers, funding, clinical trial subjects, or time to answer every important clinical question, much less to provide answers applicable in all patient populations. That said, while we ought to use our brains, we ought also to be aware that they don’t always work as well as we’d like, and are liable to trick us more often than we think.
Dr. Rose,
I appreciate your remarks and viewpoint, but let me be clear that I do not appeal to “common sense,” as the concept has no good definition. Pitting EBM against common sense is not going to clarify the issues at stake. Elsewhere (http://alertandoriented.com/tag/medical-decision-making/) I discuss various aspects of medical decision-making. The point is that the realm of relevant evidence is much richer than what can just be obtained by clinical trials and meta-analysis. To the extent that these forms of evidence are favored, clinical medicine is diminished.
I would characterize the examples that you list as “established wisdom” rather than common sense. Most of these discarded tenets were elevated to the status of clinical dogma in the ivory tower of academia. For example, many practicing physicians were wary of using HRT, despite the fact that the academic leadership was generally enthusiastic about it. I know of a case series from the 1950’s using reserpine (a “proto beta-blocker) to slow the heart rate and successfully treat heart failure. That series was published by an ordinary cardiologist. There are other examples. The dominance of academic centers in American clinical medicine is a built-in feature of our system (as historian Kenneth Ludmerer showed), but it does not have to be that way.
I agree with you that we ought to use our brains, and it would be foolish to discard data obtained from clinical trials. But we ought to use our brains more fully and not put them on an EBM auto-pilot mode.
You may be interested in Trisha Greenhalgh’s experience with EBM. See
https://www.youtube.com/watch?v=qYvdhA697jI&list=PLPdZt8Yjl_fCdMQiFysZUAgGlFz2g2t-T&index=5
Terrific. Thank you from bringing it to my attention.