Is evidence based medicine flawed?

 

Some joker on Twitter called Chrimes took this at Aspen, Colorado

Some joker on Twitter called Chrimes took this at Aspen, Colorado

Just read this intriguing open access BMJ article by Trisha Greenhalgh, Dean for Research Impact. I follow her on Twitter and she posted the article link just now.

Evidence based medicine: a movement in crisis?

Its a worthwhile read as it echoes a lot of my concerns about the way Evidence based medicine is being promoted , almost like a religion. In medicine, EBM has been touted as the way towards excellence and truth and yet for a few years now I have been wondering if it has in fact taken us further and further away from the patient. When I do remote GP medicine consultations I often find the patients are really confused about issues that are presented in EBM fashion…for example prostate cancer screening discussion ends up with the proverbial “well Doc, whatever you think is best!”

This article outlines a lot of my concerns about where EBM philosophy is taking us in medicine and it sounds out a note of caution and the need to change our direction, back towards things that in my opinion, matter. Particularly in prehospital and retrieval medicine, I dont think we will ever get “gold standard” RCT placebo controlled evidence for a lot of what we do. Does it matter? Yes and No!

I recently was having a bit of a debate on Emcrit about adrenaline for out of hospital cardiac arrest and I got a bit fed up with the usual party line of EBM saved us from our ignorance and brought the light of science to shine out the darkness..well that was being argued ;-)…and the insistence that EBM is the only way towards truth..well I dont think its the only way. Trisha argues EBM has been misused and I agree. We need expert opinions, we need tacit knowledge. We need more judgements, not more rules!

Caution : There are hazards that exist that are not Marked!

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One thought on “Is evidence based medicine flawed?

  1. Trisha Greenhalgh’s essay is very good and the purpose of it is the call to return to some of the root principles expounded by the originators of the term. Thus the “real EBM” movement.

    The important part of EBM is the philosophical approach to empirical knowledge – that there are certain ways of knowing that provides more reliable predictions of future events. Certain types of evidence is better than others for this purpose (e.g., clinical study evidence gives better predictions of empirical phenomena than pathophysiological rationale and expert opinion where available for the specific question).

    The reason we even need to recognise this is historical/cultural in nature. It was not so long ago that the prevailing attitude of medical practitioners was that experience in itself either trumped or could replace the need for other types of evidence. These beliefs haven’t disappeared and underlies some of the anti-academic attitudes out there (e.g., every time the words “ivory tower” is used for inconvenient results without appraisal).

    Empirical evidence tells us what we know, not what we should do. Clinical judgment and understanding patient preferences and values is vital and evidence from research does not replace this. This was David Sackett’s model of EBM, the intersection of best evidence, clinical judgment, and patient values.

    Cheers,
    Michael

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