Medical science Archives - Page 3 of 8

How I learned to stop worrying and love practicing without EBM

Michel AccadSeptember 30, 2016July 31, 2020Medical scienceevidence-based medicine1 Comment

If you’ve enjoyed my previous take-downs of evidence-based medicine but can’t let go of your attachment to the randomized controlled trial, this post is for you.

My aim is to show you practical ways you can safely and effectively exercise clinical judgment without recourse to “evidence-based” knowledge, provided you follow simple but fundamental principles of clinical care: circumspection, parsimony, and due respect to patient autonomy.

What’s more, I will make my case against RCTs using examples that EBM apologists have precisely identified as paradigmatic of this “single greatest medical advance.”Continue reading “How I learned to stop worrying and love practicing without EBM”

Three cheers for the statin war

Michel AccadSeptember 15, 2016December 13, 2016Healthcare policy, Medical scienceevidence-based medicine15 Comments

If anyone has any lingering doubts that the promises of evidence-based medicine are quickly evaporating, the recent blog post by Larry Husten on the statin war should quickly dispel them. Husten gives an excellent account of the latest battle opposing the pro- and the anti- camps.

What happened?

The pro-statinists published a 30-page diatribe in The Lancet. Statins save lives, they assert. The evidence is incontrovertible. Yes, they can have side effects such as muscle pain, no one disputes that. But drawing attention to those side-effects—as the anti-statinists do—endangers patients who now find a reason to refuse to take the life-saving drugs. There’s evidence of that happening.

The anti-statinists voiced their position in the BMJ. Statins cause muscle pain and fatigue, they assert. The evidence is incontrovertible. Yes, they can save lives, no one disputes that. But trumpeting the benefits or down-playing the harm—as the statinists do—prevents patients from partaking in the glorious activity of “shared-decision making.” There’s evidence of that happening.Continue reading “Three cheers for the statin war”

Beauty, chemistry, and natural philosophy

Michel AccadAugust 11, 2016December 13, 2016Medical science, Philosophy6 Comments

About a year ago, Theral Timpson interviewed Stanford chemist Carolyn Bertozzi on his Mendelspod podcast. I only heard the show recently and enjoyed it. The title caught my attention: “Is the future of biology a return to chemistry?”

Bertozzi made some interesting comments about her field, which she regards as “the central science,” and Timpson probed her about her expectations for the place of chemistry in what is otherwise expected to be “the century of biology.”

The discussion was of interest to me for two reasons.Continue reading “Beauty, chemistry, and natural philosophy”

The mother of all medical errors

Michel AccadJuly 14, 2016December 13, 2016Ethics, Healthcare policy, Medical science, Philosophy2 Comments

A study published a couple of months ago in the BMJ made headlines for claiming that medical errors are the third leading cause of death. As expected, the reactions were swift and polarized.

For some, the study confirmed that the self-serving healthcare system is utterly careless about the welfare of patients. For others, the claim was complete hogwash, based on faulty methodology designed to justify further regulatory oversight.

The two positions are not necessarily mutually exclusive.Continue reading “The mother of all medical errors”

Risk-factor medicine

Michel AccadJuly 8, 2016December 13, 2016Medical science6 Comments

If concepts could get awards, then “risk factor” would surely be a Nobel prize winner. Barely over 50 years of age, it enjoys such an important place in medicine that I suspect most of us doctors could hardly imagine practicing without it. Yet, clearly, the concept is not native to our profession nor is its success entirely justified.

A few years ago, on the occasion of the risk factor’s fiftieth anniversary, my colleague Herb Fred and I published an editorial highlighting some of the problem with the use of this concept. I will summarize here some of those points.Continue reading “Risk-factor medicine”

Risk factors, causes, and the diet-lipid hypothesis

Michel AccadJuly 1, 2016December 13, 2016Medical science, Philosophy4 Comments

I shared with a reader an editorial I co-wrote in 2010 entitled “Risk-Factor Medicine: An Industry Out of Control?” Subsequently we had the following e-mail exchange, which I thought might be of interest to other readers of Alert and Oriented. I was impressed by Robert’s comments and learned a few things from him and from the links he provided.

On April 29, 2016, Robert wrote:Continue reading “Risk factors, causes, and the diet-lipid hypothesis”

Against surgical excellence

Michel AccadMay 19, 2016December 13, 2016Healthcare policy, Medical sciencemedical decision-making2 Comments

A Vox.com piece about decision-making caught my attention this morning.

The story was compelling. A 12-year-old boy had intractable seizures from a leaking vascular malformation in the brain. A first neurosurgeon would not operate and recommended radiation therapy instead. The patient’s mother sought another opinion from a Mayo Clinic neurosurgeon who was adamant that an operation should be undertaken. The second surgeon surgeon was undeniably right. The patient is now a bright, fully-functional researcher at the University of California San Francisco.

So far, so good? Not so, according to Vox. That there should be a smart mom making a smart decision, and a smart doctor carrying out a successful surgery is apparently a problem.

Why? Because the more cautious surgeon had a different opinion and, had the mom compliantly accepted his recommendation, the child could have been worse off. Variability in judgment, as always, is the enemy.Continue reading “Against surgical excellence”

A free market repudiation of evidence-based medicine

Michel AccadMay 13, 2016December 13, 2016Healthcare economics, Healthcare policy, Medical scienceevidence-based medicine6 Comments

In a recent article entitled “A Hayekian Defense of Evidence-Based Medicine” Andrew Foy makes a thoughtful attempt to rebut my article on “The Devolution of Evidence-Based Medicine.” I am grateful for his interest in my work and for the the kind compliment that he extended in his article. Having also become familiar with his fine writing, I return it with all sincerity. I am also grateful to the THCB staff for allowing me to respond to Andrew’s article.

Andrew views EBM as a positive development away from the era of anecdotal, and often misleading medical practices: “Arguing for a return to small data and physician judgment based on personal experience is, in my opinion, the worst thing we could be promoting.” Andrew’s main concern is that my views may amount to “throwing the baby with the bath water.”

On those counts, I must plead guilty as charged.Continue reading “A free market repudiation of evidence-based medicine”

Book review: How Doctors Think

Michel AccadMay 4, 2016December 13, 2016Medical practice, Medical science, Philosophymedical decision-makingLeave a comment

Kathryn Montgomery’s How Doctors Think: Clinical Judgment and the Practice of Medicine is an excellent book that was brought to my attention by Dr. James Gaulte in the comment section of my post on phronesis. Indeed, much of Montgomery’s monograph deals with the Aristotelian concept of practical wisdom applied to clinical decision-making.

The author is Professor of Medical Humanities and Bioethics and Professor of Medicine at Northwestern University Feinberg School of Medicine. Her book is too rich to cover deeply in a short review, but I’d like to highlight some of its major strengths as well as a few minor weaknesses.

In the first part of the book, Montgomery thoroughly demolishes the notion that medicine is applied science.Continue reading “Book review: How Doctors Think”

The war on the NEJM

Michel AccadApril 30, 2016December 13, 2016Healthcare policy, Medical scienceconflict of interest1 Comment

The war against the New England Journal of Medicine has gained visibility after Charles Ornstein traced its developments in the pages of the Boston Globe. The story was amplified in a number of trade publications, and was even picked up by a NPR-affiliated show.

This has emboldened the attackers to open fire on Twitter with calls for “transparency,” “open science,” and a “unified research community.” Their ideological alliance is with the BMJ.

A users guide to key differences between @bmj_latest and @NEJM pic.twitter.com/vXZElda4wD

— Vinay Prasad (@VinayPrasad82) April 21, 2016

Those who refuse to partake in the cause of transparency live in a world of “silos,” “conflicts of interest,” and “industry ties.”

Bottom line: lots of trialists don’t want to share their data. Not really a surprise. But a shame IMHO. https://t.co/9PcScwpLur #openscience

— Harlan Krumholz (@hmkyale) April 29, 2016

The NEJM‘s lukewarm attitude towards the movement is “an oppression,” says Eric Topol, as quoted by Ornstein. Did he intend to use a term with Marxist connotation? The loose coalition of scientists, healthcare journalists, and muckrakers ready to overthrow the established order might as well be known as the Data Liberation Front!Continue reading “The war on the NEJM”