The 'real' in the 'real patient' of the position paper on ‘realEBM’ (Greenhalgh et al BMJ 2014;348:g3725) seems to refer to the actual concrete person, the individual in front of you the practitioner, and to a shift in practice that focuses more on this ‘real individual’ and away from a one size fits all 'EBM'.
Whilst this is a shift in the right direction I argue that the ‘realEBM’ principles don’t go far enough because they miss out on two important features: a) of our subjectivity as social individuals that are both ‘subject to’ and ‘agent of’ societal institutions that at least in part construct our subjectivity, our subject-position or role, and b) of the crucial role that the norms of society have in limiting what it is acceptable to say and challenge .
The article misses out on a wide range of important and influential ideas based upon decades of work by such thinkers as the economic and ideology theorists Marx1, Althusser2, (The Frankfurt School)3, Foucault4, amongst many others and the psychoanalytic and language theorists such as Pêcheux5, Lacan6, and Parker7.
These ideas go a long way, for example, to helping us understand the origins of the vehement ‘turf’ wars between the breast cancer pro-screeners and the screening ‘sceptics’. (or more recently the pro-Statins versus the Statin-sceptics) They also help us to understand the apparently conflicted and fluctuating situations and responses revealed by subject narratives, such as those reported by the two women invited for breast cancer screening in 2012 and reported on The Today programme in 2012.8
In an important sense the 'patient' or human subject's existence is not 'real', it is as common sense dictates actually lived and experienced but it is based upon what is essentially how we ‘imagine’ our relationships with each other and the world to be, rather than how they actually are. and this has implications for how we (medical practitioners) respond to the relationships between the institutionalised management of medical knowledge, medical practice and the subject. The reason that the subject is not 'real' (and why realEBM will be an unhelpful rebranding) is because we are continually responding to the societal normative demands to fulfil certain roles within society in such a way that our lived experiences are based on the way we imagine those relationships to be and not on the real existing relationships. This is one definition of ideology. Those imaginary aspects of our subjectivity can be extremely strong and this can explain why in history we can see good and sincere people doing dangerous things.
There is danger too when the article suggests that the doctor's role is: "...to find out what matters to the patient." And “...what is the best course of action.” This suggests a delusion on the part of the doctor that he/she can ever access what 'matters' to another subject. (And this isn't the same as saying that the doctor shouldn't facilitate an exploration of 'ideas, concerns and expectations').
By ignoring the imaginary nature of these relationships the realEBM brand will perpetuate the imbalances in power relationships within the triad of the biotechnological industries (via political and economic drivers), medical practice and the subject consumer of 'healthcare' (technological products mediated/sold by medical practitioners).
This is not just academic idealism either, in a practical sense the analysis of the current discourses within healthcare can do much to provide the subject with tools to resist. The subject in front of you is already a subject of our biotech industrial age and judging by demands on health services frequently conditioned to want to consume biotechnologies and then to demand more of the same. Practitioners aware of this can strive to expose and challenge unjustified rhetoric from the institutions and demand more honesty about uncertainty.
The title of the article includes: ‘Evidence Based Medicine’. Does this carry a meaning suggesting (can it be paraphrased) Medicine that is Evidence Based, or that is ‘to be’ Evidence Based, or Medicine ‘should’ be Evidence Based. For an average reader is the effect to suggest that all of Medical Practice must be Evidence Based. Evidence or ‘culturally managed medical knowledge’ does not subsume or transcend Medical Practice, it’s the other way round. If this is the case then name ‘EBM’ as used here is misleading and a misnomer.
EBM seems to be a subject with many properties: it possesses tools and a crisis, it is a community, it is a science. Yet it is a practice practiced by practitioners.
The term EBM is a misleading misnomer that encourages policy makers and practitioners to believe that the knowledge they manage, manufacture, and use, is more powerful than it can (or should) be. It isn’t EBM that is doing the harms of over-diagnosis etc ( as well as much good) it is the practice of medicine.
Capitalism and celebrating medical mastery need to be challenged: As well as ‘political convictions’ (capitalism and the free market that frees up industry to appropriate ‘clinical epidemiology’ to its own ends) there are ‘medical convictions’ (‘to save life’ above all); and much healthcare is directed to well citizen-subjects not ‘patients’ a term used too much in this article.
Reference List
(1) Marx K. Capital; A critique of political economy vol 1 translated by Ben Fowkes. London: Penguin Books Ltd; 1990.
(2) Althusser L. Essays on Ideology. London: Verso; 1984.
(3) Adorno TW. The Culture industry. New York: Routledge; 1991.
(4) Foucault M. The Birth of the Clinic. Oxford: Routledge; 1963.
(5) Pecheux M. Language, semantics, and ideology. New York: St. Martin's Press; 1975.
(6) Lacan J. The Seminar of Jacques Lacan: The Four Fundamental Concepts of Psychoanalysis (Vol. Book XI) (The Seminar of Jacques Lacan. New York: W W Norton & Company; 1981.
(7) Parker I, Pavon Cuellar D. Lacan, Discourse, Event: New psychoanalytical approaches to textual indeterminacy. Hove: Routledge; 2013.
(8) The Today Programme. I was railroaded into cancer surgery. London BBC radio 4 [ 2012 Available from: URL:http://news.bbc.co.uk/today/hi/today/newsid_9764000/9764798.stm
Rapid Response:
The 'real' in the 'real patient' of the position paper on ‘realEBM’ (Greenhalgh et al BMJ 2014;348:g3725) seems to refer to the actual concrete person, the individual in front of you the practitioner, and to a shift in practice that focuses more on this ‘real individual’ and away from a one size fits all 'EBM'.
Whilst this is a shift in the right direction I argue that the ‘realEBM’ principles don’t go far enough because they miss out on two important features: a) of our subjectivity as social individuals that are both ‘subject to’ and ‘agent of’ societal institutions that at least in part construct our subjectivity, our subject-position or role, and b) of the crucial role that the norms of society have in limiting what it is acceptable to say and challenge .
The article misses out on a wide range of important and influential ideas based upon decades of work by such thinkers as the economic and ideology theorists Marx1, Althusser2, (The Frankfurt School)3, Foucault4, amongst many others and the psychoanalytic and language theorists such as Pêcheux5, Lacan6, and Parker7.
These ideas go a long way, for example, to helping us understand the origins of the vehement ‘turf’ wars between the breast cancer pro-screeners and the screening ‘sceptics’. (or more recently the pro-Statins versus the Statin-sceptics) They also help us to understand the apparently conflicted and fluctuating situations and responses revealed by subject narratives, such as those reported by the two women invited for breast cancer screening in 2012 and reported on The Today programme in 2012.8
In an important sense the 'patient' or human subject's existence is not 'real', it is as common sense dictates actually lived and experienced but it is based upon what is essentially how we ‘imagine’ our relationships with each other and the world to be, rather than how they actually are. and this has implications for how we (medical practitioners) respond to the relationships between the institutionalised management of medical knowledge, medical practice and the subject. The reason that the subject is not 'real' (and why realEBM will be an unhelpful rebranding) is because we are continually responding to the societal normative demands to fulfil certain roles within society in such a way that our lived experiences are based on the way we imagine those relationships to be and not on the real existing relationships. This is one definition of ideology. Those imaginary aspects of our subjectivity can be extremely strong and this can explain why in history we can see good and sincere people doing dangerous things.
There is danger too when the article suggests that the doctor's role is: "...to find out what matters to the patient." And “...what is the best course of action.” This suggests a delusion on the part of the doctor that he/she can ever access what 'matters' to another subject. (And this isn't the same as saying that the doctor shouldn't facilitate an exploration of 'ideas, concerns and expectations').
By ignoring the imaginary nature of these relationships the realEBM brand will perpetuate the imbalances in power relationships within the triad of the biotechnological industries (via political and economic drivers), medical practice and the subject consumer of 'healthcare' (technological products mediated/sold by medical practitioners).
This is not just academic idealism either, in a practical sense the analysis of the current discourses within healthcare can do much to provide the subject with tools to resist. The subject in front of you is already a subject of our biotech industrial age and judging by demands on health services frequently conditioned to want to consume biotechnologies and then to demand more of the same. Practitioners aware of this can strive to expose and challenge unjustified rhetoric from the institutions and demand more honesty about uncertainty.
The title of the article includes: ‘Evidence Based Medicine’. Does this carry a meaning suggesting (can it be paraphrased) Medicine that is Evidence Based, or that is ‘to be’ Evidence Based, or Medicine ‘should’ be Evidence Based. For an average reader is the effect to suggest that all of Medical Practice must be Evidence Based. Evidence or ‘culturally managed medical knowledge’ does not subsume or transcend Medical Practice, it’s the other way round. If this is the case then name ‘EBM’ as used here is misleading and a misnomer.
EBM seems to be a subject with many properties: it possesses tools and a crisis, it is a community, it is a science. Yet it is a practice practiced by practitioners.
The term EBM is a misleading misnomer that encourages policy makers and practitioners to believe that the knowledge they manage, manufacture, and use, is more powerful than it can (or should) be. It isn’t EBM that is doing the harms of over-diagnosis etc ( as well as much good) it is the practice of medicine.
Capitalism and celebrating medical mastery need to be challenged: As well as ‘political convictions’ (capitalism and the free market that frees up industry to appropriate ‘clinical epidemiology’ to its own ends) there are ‘medical convictions’ (‘to save life’ above all); and much healthcare is directed to well citizen-subjects not ‘patients’ a term used too much in this article.
Reference List
(1) Marx K. Capital; A critique of political economy vol 1 translated by Ben Fowkes. London: Penguin Books Ltd; 1990.
(2) Althusser L. Essays on Ideology. London: Verso; 1984.
(3) Adorno TW. The Culture industry. New York: Routledge; 1991.
(4) Foucault M. The Birth of the Clinic. Oxford: Routledge; 1963.
(5) Pecheux M. Language, semantics, and ideology. New York: St. Martin's Press; 1975.
(6) Lacan J. The Seminar of Jacques Lacan: The Four Fundamental Concepts of Psychoanalysis (Vol. Book XI) (The Seminar of Jacques Lacan. New York: W W Norton & Company; 1981.
(7) Parker I, Pavon Cuellar D. Lacan, Discourse, Event: New psychoanalytical approaches to textual indeterminacy. Hove: Routledge; 2013.
(8) The Today Programme. I was railroaded into cancer surgery. London BBC radio 4 [ 2012 Available from: URL:http://news.bbc.co.uk/today/hi/today/newsid_9764000/9764798.stm
Competing interests: No competing interests