Evidence-Based Medicine
A paper by Twila Brase, RN, PHN, president of the Minnesota-based Citizens Council on Health Care, and published by ALEC, explains the dangers of relying solely on “evidence based medicine” (EBM) to determine appropriate treatment for an individual patient. The problems are too long to list here, but they include:
- Researcher bias when the researcher conducting the study has a preference for one form of treatment over another. Sometimes this may involve financial incentives, but that is not the only or even the major source of bias.
- Conflicting results. This happens all the time in research. One study contradicts another, and neither may be completely accurate.
- The expense, and therefore the rarity, of conducting randomized clinical trials. Very little medicine would be conducted if these trials controlled what could be done.
- Comorbidities. Clinical trials focus on only one condition at a time, but few patients present with just one issue. There is a little information available about how multiple conditions and multiple treatments interact.
- Special interest pleading. Well-organized interest groups are able to influence what topics are researched and how the research is conducted.
- Lack of real-world testing. What works in the lab may break down on the battlefield of real life.
These problems are compounded by the profusion of clinical guidelines that are based on this error-filled research. Ms. Brase points out that the National Guideline Clearinghouse currently contains 5,899 sets of guidelines, with nearly 500 more being added every year. Some of these sets contain hundreds of pages, and often there are several different guidelines for the same condition. She writes, “the Clearinghouse contains nine guidelines totaling 165 pages written by seven different organizations for the treatment of middle ear infections.”
All of that is just the beginning of the problems with EBM. The far bigger issue is how it is to be applied and enforced. The obvious goal is to control physicians’ behavior. The dean of the Boston University Scholl of Public Health is quoted as saying, “Variations from these best practices should be defined as medical errors.” Ways to enforce standardization include protection from malpractice for compliance and “pay for performance.”
Ms. Brase concludes, “The danger to patients is real. If EBM becomes the legal standard of care, physicians and doctors will no longer have medical decision-making authority or professional autonomy. Patients in every corner of the nation will be left vulnerable to the personal preferences, financial agendas, value-laden opinions, and political biases of people who do not even know their name.”
Good post, Greg. And a nice complement to the previous post describing the results of the CBO studies.
Imagine what would happen if we had eveidenced based economics? Economists would have been prevented from teaching Keynesean ideas for the last three decades.
Then, when we have a crisis where Keynesean prescriptions might be approprisate, no one would know anything about it.
Greg, I think you, and perhaps Twila, have missed the most important problem. Evaluating the evidence takes time. By the time the evaluation is done to everyone’s satisfaction, the frontiers of medicine have moved way beyond the procedure in question.
So the cutting edge treatments will never be evidence based in the sense you mean it here. And if we insist that third parties only pay for treatments that have been fully evaluated, people will be systematically denied access to cutting edge medicine unless they pay for it out of their own pockets.
Evidence-based medicine is medicine based on statistical averages, as in it works for 54 percent of people so use it on everyone.
If it were applied to women’s fashion, all women would be wearing a size 12 dress.