Evidence Based Medicine [often pronounced evidencebasedmedicine] has evolved into one of my least favorite terms, even beating out chemicalimbalance. The reason it tops the list is that it’s even used by people who are not tricksters like the chemicalimbalance set. They often mean well. They’re saying that you shouldn’t confuse opinion or preference with fact, that too many people in this world render expert medical opinions or advice that aren’t backed up by anything factual – and that’s an excellent point. There’s a background implication that people in medicine who do this shoot-from-the-hip thing are charlatans with ulterior motives. So if I’m extolling the virtues of evidencebasedmedicine, why is it my least favorite term? Well, part of the answer is PTSD. If you were in psychoanalytic training in the late 1970s or early 1980s, you would’ve been bludgeoned with "what is the evidence for…?" questions or been seen as a necromancer or worse so many times that you wince at the mention. Being a psychiatrist wasn’t much better with the Szaszian critiques or the reductionistic-medical-model-thinking criticisms that seemed to come out between the bricks and through the cracks in the windows. These days, it’s being put in the position of defending the belief that all mental illness is brain disease treatable with toxic chemicals. I’m obviously really not very good at that one. So, to summarize, many people use the term evidencebasedmedicine to say, "You’re a deluded lunatic."
But that’s not why it’s my least favorite term. It’s because it has been turned into a trick, a surrogate for the scientific method. And it has become an agent of harm. Three years ago, I drew the picture on the left to diagram EMB as it was being presented in a particular article: Structured Interview, Diagnostic Manual, Treatment Algorithm informed by Clinical Trials, resultant Treatment recommendation based on EBM treatments. On the right, I’ve circled the elements that have been regularly misused in one or another form of corruption. Every one of them vulnerable to misuse by the prophets of evidencebasedmedicine:
In fact, there’s really only one kind of Medicine, and it’s Evidence Based Medicine. But many now use evidencebasedmedicine as a false certification of their distortions due to conflictsofinterest. That’s my introduction to this article:
by Des SpenceBritish Medical Journal. 2014 348:doi: [Published 3 January 2014]Evidence based medicine [EBM] wrong footed the drug industry for a while in the 1990s. We could fend off the army of pharmaceutical representatives because often their promotional material was devoid of evidence. But the drug industry came to realise that EBM was an opportunity rather than a threat. Research, especially when published in a prestigious journal, was worth more than thousands of sales representatives. Today EBM is a loaded gun at clinicians’ heads. “You better do as the evidence says,” it hisses, leaving no room for discretion or judgment. EBM is now the problem, fueling overdiagnosis and overtreatment.
You see, without so called “evidence” there is no seat at the guideline table. This is the fundamental “commissioning bias,” the elephant in the room, because the drug industry controls and funds most research. So the drug industry and EBM have set about legitimising illegitimate diagnoses and then widening drug indications, and now doctors can prescribe a pill for every ill. The billion prescriptions a year in England in 2012, up 66% in one decade, do not reflect a true increased burden of illness nor an ageing population, just polypharmacy supposedly based on evidence. The drug industry’s corporate mission is to make us all sick however well we feel. As for EBM screening programmes, these are the combine harvester of wellbeing, producing bails of overdiagnosis and misery.
Corruption in clinical research is sponsored by billion dollar marketing razzmatazz and promotion passed off as postgraduate education. By contrast, the disorganised protesters have but placards and a couple of felt tip pens to promote their message, and no one wants to listen to tiresome naysayers anyway.
How many people care that the research pond is polluted, with fraud, sham diagnosis, short term data, poor regulation, surrogate ends, questionnaires that can’t be validated, and statistically significant but clinically irrelevant outcomes? Medical experts who should be providing oversight are on the take. Even the National Institute for Health and Care Excellence and the Cochrane Collaboration do not exclude authors with conflicts of interest, who therefore have predetermined agendas. The current incarnation of EBM is corrupted, let down by academics and regulators alike.
What do we do? We must first recognise that we have a problem. Research should focus on what we don’t know. We should study the natural history of disease, research non-drug based interventions, question diagnostic criteria, tighten the definition of competing interests, and research the actual long term benefits of drugs while promoting intellectual scepticism. If we don’t tackle the flaws of EBM there will be a disaster, but I fear it will take a disaster before anyone will listen.
Corruption of the Evidence as Threat and Opportunity for Evidence-Based Medicine
Victor M. Montori, MD, MSc
and Gordon H. Guyatt, MD, MSc
medicossinmarca.cl/wp-content/uploads/2012/07/Corruption-of-the-Evidence-as-Threat-and-Opportunity-for-Evidence-Based-Medicine.pdf …
“In this review, we will consider the ongoing challenges to the practice of evidence-based medicine. In particular, we will note how trends in research conduct have corrupted the evidence chain.”
Gordon H. Guyatt, MD, MSc is an internist and clinical epidemiologist. He coined the term ‘evidence-based medicine’ and has dedicated his career to its promotion. In over 600 publications, he has made landmark contributions to quality of life measurement, randomized trial and systematic review methodology, and standards for practice guidelines
Where’s the like button?
I hate the word “resilience” which is not evidence-based. Not to long ago, I read an article describing a couple that had been marred by a bear. The husband seemed to be dealing well, got custody of his children, and was functioning well. Because, you see, he was resilient. She, was a mess. Because, you see, she wasn’t resilient. Does this call for anipso facto and a reverse inference, or what? The article was so loaded for and with this marketing term (for a resilience- building enterprise, no doubt) that it described how the woman’s face was horribly disfigured and her husband’s was untouched with no apparent self-awareness at all.
too long ago and mauled by a bear. Sheesh. I was using OpenWord, too.