Evidence based medicine is broken
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g22 (Published 03 January 2014) Cite this as: BMJ 2014;348:g22
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Assuming that the basic argument is correct, i.e. EBM is somewhere near the end of a process of being seriously corrupted by the publication of biased reports sponsored or written by the pharmaceutical industry, where are the safeguards attended to prevent such publications?
Where are the editors of the "prestigious journal[s]" and their merry band of peer-reviewers? Is everyone on the "take" or asleep? Who let the "fake" evidence into the print room or let it seep online in pdf?
I find it hard to believe that honest, hard-working journal editors and peer-reviewers the world over are being consistently blindsided by malicious article writers to such a degree that EBM is no longer valid.
Granted this piece is short, but some definable analysis is essential. So how much of the pond/ocean is actually polluted?
Competing interests: No competing interests
While some hyperbole is essential to attract discussion, I agree with a fair bit of Dr. Spence's editorial. There is room for improvement of the creation of empirical data to improve patient care.
However, physicians and patients are not robots and cannot be expected to behave accordingly. While data is created by trials for the average patient, the learned intermediary clinician is obligated to exercise their judgment (a la off label prescribing permitted under US law).
Mentorship is a cornerstone of learning and clinical judgment is making a comeback as a powerful albeit different tool - its not at the bottom of the EBM pyramid, perspective is not data, and should be removed from that slot. It should rather be evaluated in its own paradigm of experience, including giving credence to conflicts of interest and many other factors that can make someone an "expert" - or not.
See the GRADE Working Group and efforts to set data alongside clinical judgment.
Competing interests: Publisher of The Medical Roundtable peer-reviewed expert roundtable discussions based in the evidence.
I couldn’t agree more with the author of this paper and I applaud the brave act of discussing this controversial issue in public. I disagree that discussing such issues is putting the blame on the ‘big bad drug companies’ like Dr Spence has said NICE and the Cochrane Collaboration are just as much to blame for not scrutinising drug companies who conduct research with conflicts of interest.
The reality is that this is a complex global issue with no one answer and it’s only from being able to debate in a professional and transparent context can we learn and move on. Thank you for your article Dr Spence, it’s good to see that there are still clinicians who care enough to speak about such controversial and highly political matters in public forums.
Competing interests: No competing interests
EBM is actually statistical EBM. Statistics comes from data gathered from many people. Since most people have automatic negative thoughts and automatic stress response, most people are constantly creating stress hormones to destroy their own body cells, the extent of which, however, is not measured in most clinical trials.
Thus it is logical to conclude that while statistically based EBM, even if not distorted by big pharma, may only apply to the average person whose stress is repressed. It cannot apply to a truly subconsciously positive thinker. In fact longevity is increased by positive self perception of aging ( http://www.ncbi.nlm.nih.gov/pubmed/12150226).
Yet doctors are more or less forced by EBM to teach all patients, including positive thinkers, into thinking towards the negative whenever they have perception of dis-ease/disease. A form of guided imagery where people are trained to look more at the darker side of any perception of body discomfort which could actually have arised from subconsciously repressed stress in daily life. Statistical EBM neglects the fact that everyone is different. Albert Einstein said— 'Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid.'
Thus I think that EBM, even if not biased by big pharma, is itself a form of of truth but partial truth/bias, being biased by the material biomedical model since Virchow 1865. Lord Mustill once said - Partial truth can be as misleading as an untrue statement. We as doctors have neglected the bio-psychosocial model of disease (Engel 1977), leaving room for the flourishing of placebo/ritual eastern medicine which however had been proven recently to cause real changes in our brain and body similar to those produced by drugs (http://www.ncbi.nlm.nih.gov/pubmed/21621366).
Due to the science of neuroplasticity in the last decade, it proved that everyone has the ability and potential to change to positive thinking with adequate training with mind methods, through rewiring their own brain.
Thus even if EBM is not broken, it is already 20 years old when fMRI....is just in its infancy. Brain functional science gradually showed that EBM is a biased and hence outdated method to fairly judge the effect of material on body as almost all clinical trials did not show the effect of subconsciosu stress (past psychosocial experience history) on the body, even though there are some clinical trials done on conscious stress in terms of questionnaires to gauge the subjective feeling of patients.
I am not biased towards psychological medicine as it may kill people due to delay in material therapy. A balance should be sought for each patient by a person properly trained or experienced in both material methods and mind methods.
EBM often neglects how the patients perceive the drugs they are taking, and this is very important according to Harvard researcher Ted Kaptchuk in JAN 2013
(http://harvardmagazine.com/2013/01/the-placebo-phenomenon).
Doctors should be open minded positive thinkers, looking for what is best for patients, rather than confined to framed/segmented bio-medical knowledge. The more we use tunnel vision to focus on segmental interest or research on EBM, the more biased and more further away from health we become as far as patient health is concerned. EBM is just a means (one method) to an end (health for patients).
Competing interests: No competing interests
Until medical education teaches medical students and doctors to think critically and sceptically and question what we are taught, often by rote or example with learning objectives to be fulfilled and exam questions to be answered with the 'right answers' - we will continue to suffer the problems Des lists. The commonest question medical students ask of their teachers is, "tell us what we need to know [to pass our exams]" Some have even complained to me that I've asked them 'to think' too much.
Doctors are too often the un-sceptical consumers of knowledge, guidelines and protocols which are enforced with financial incentives like QoF. We need to teach wisdom and we need to forge closer allegiances with sceptical patients so that together we are critically appraise what modern medicine has to offer .
Competing interests: No competing interests
The implication, from several of the responses, seems to be that EBM is 'broken' because it has been 'fixed'
IE
Its 'broken'.. because the 'fixing' is the reason for it being broken?
And therefore it needs..... further fixing?
Competing interests: No competing interests
Scare-care is a poor substitute for healthcare. Healthcare experts who manufacture public hysteria about controversial issues, without acknowledging the legitimacy of opposing points of view, are not advancing public health. Healthcare is not monolithic, and there are legitimate questions about such sacred cows as vaccines, statins, tranquilizers, antidepressants, and global warming (climate change). Healthcare requires balance and fairness, not bias and fear.
Competing interests: None relevant.
Whilst I agree with much of Dr Spence's article I do get embarrassed by my profession's constant bleating about the big bad drug industry. We appear to have adopted a position of learned helplessness. Drug reps do not make diagnoses and do not sign prescriptions.
Competing interests: No competing interests
A well, another year and another diatribe on the current fashionable topic of conflicts of interest - or to be precise, financial conflicts of interest. If Des Spence is to be believed, we should discard all current medical research due to the flaws he clearly believes to be present in all studies. As for the comment on medical experts being on the take, people have been sued for less.
While it is undoubtedly true that there are medical experts and others who take the drug companies shilling to slant research results, the suggestion that all doctors have no professional or moral standards and will sell their soul for a free conference place or something is insulting in the extreme.
If you take an objective look at the declarations of interest associated with any good quality guideline you are likely to find that in fact most people do not have conflicts. There are always a few that do, but as long as everyone is aware of them and takes them into account they should not be able to force their own views on others as long as the group is well managed (as most of them are).
I think the focus on financial conflicts is unfortunate, as it draws attention away from a much more difficult problem - non financial conflicts. Many people who have been involved in a field for a long time will have established views that they will not give up easily. Perhaps we should focus more on the published opinions of guideline developers or systematic reviewers? How about patient advocacy groups? Do we believe only doctors are prone to bias?
I do agree with Des Spence and others that drug trials have 'corrupted' EBM, not necessarily for sinister reasons but because they are often the easiest topics to do RCTs for. The primacy of RCTs does tend to favour drug recommendations over others, and that is not an easy problem to solve. It can only be addressed if bodies other than big pharma are prepared to fund trials in other areas.
Lastly, can I point out that in guidelines at least only a minority of recommendations relate to drugs. EBM might not be totally useless after all.
Competing interests: Long term involvement in EBM and guideline development
Re: Evidence based medicine is broken
I always thought that Evidence-Based recommendations were promoted by practice managers and insurers, because those recommendations were less costly. Why? Because the best evidence favors the oldest drugs, which have been tested the longest, and are most likely to be available as generics. This would be contrary to Industry's efforts to promote newer, more expensive agents. Either way, evidence is corrupted by economics.
Competing interests: No competing interests