Great rebuke of "evidence-based medicine."

[Monty Python]

A great (and very well-written) rebuke of "evidence-based medicine" by an anesthesiologist, who herself was a patient recently. Highly recommended reading.

http://members.csahq.org/blog/2014/02/18/today’s-“evidence-based-medicine”-may-be-tomorrow’s-malpractice

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[sunealoneal]

Aren't the various meta-analyses cited throughout this article examples of evidence-based medicine? And isn't citing the lack of a controlled study regarding this SCIP beta-blocker measure an appeal to evidence-based medicine?

Perhaps the overarching point is going over my head.

 

[Consigliere]

A great (and very well-written) rebuke of "evidence-based medicine" by an anesthesiologist, who herself was a patient recently. Highly recommended reading.

http://members.csahq.org/blog/2014/02/18/today’s-“evidence-based-medicine”-may-be-tomorrow’s-malpractice

Several years old

 

[Urzuz]

Aren't the various meta-analyses cited throughout this article examples of evidence-based medicine? And isn't citing the lack of a controlled study regarding this SCIP beta-blocker measure an appeal to evidence-based medicine?

Perhaps the overarching point is going over my head.

The takeaway point for me is that though evidence-based medicine obviously holds a critical place in medical practice and has led to a number of advances in care (EGDT, therapeutic hypothermia, even ACLS), we have to be mindful that even the highest standard we have of evidence-based medicine, i.e.: meta-analyses, can be influenced by external biases and factors that the reader may not be aware of. Also, another big point for me is that though ONE study may have dramatically positive results, we should all be weary of making changes to our practices until the results are shown to be reproducible by other investigators.

 

[urge]

A great (and very well-written) rebuke of "evidence-based medicine" by an anesthesiologist, who herself was a patient recently. Highly recommended reading.

http://members.csahq.org/blog/2014/02/18/today’s-“evidence-based-medicine”-may-be-tomorrow’s-malpractice

Don't think that is what the article says.

It's more like fraud is rampant in medical research and policy making.

 

[deleted171991]

The takeaway point for me is that though evidence-based medicine obviously holds a critical place in medical practice and has led to a number of advances in care (EGDT, therapeutic hypothermia, even ACLS)

We consider them advances, except that there is more and more contradicting evidence for each of your examples.

EGDT is half-dead, at least in the Manny Rivers version. CVP, ScvO2, tons of fluids etc., all proven worthless. Therapeutic hypothermia is proven again and again to be worthless. The main "proven" benefit is after ventricular arrhythmia leading to arrest, and even that one is debated. Same goes for CPR as it is taught. There is more and more debate that the way we are doing CPR is bad (mechanically). Not only that, but basic tenets such as "no/minimal interruptions" are very debatable.

The problem with medical "research" is that it has turned into a multi-billion dollar publishing industry, which doesn't really care about quality, just quantity. Instead of publishing only passionate and well-proven research, a lot of POS gets published even in the big name journals. Full of smoke and mirrors, which then gets used in malpractice suits.

Also, another big point for me is that though ONE study may have dramatically positive results, we should all be weary of making changes to our practices until the results are shown to be reproducible by other investigators.

100% agree. Science should be reproducible. It shouldn't be treated as scientific evidence until it is repeatedly, independently reproduced, in a rigorous scientific environment.

 

[deleted171991]

Crit Care Med. 2010 Oct;38(10 Suppl):S534-8. doi: 10.1097/CCM.0b013e3181f208ac.
We should abandon randomized controlled trials in the intensive care unit.
Vincent JL1.
Author information

• 1Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium. [email protected]

Abstract
The randomized controlled trial is seen by many as the summit of evidence-based medicine, yet, in the intensive care unit, randomized controlled trials can be challenging to conduct, and results are often difficult to interpret and apply. Many randomized controlled trials in intensive care patients have not demonstrated beneficial effects of the intervention under investigation often despite good preclinical and even previous randomized controlled trial evidence. There are many reasons for these negative results including problems with timing, end point selection, and heterogeneous populations. In this article, we will discuss the limitations of randomized controlled trials in the intensive care unit population and highlight the importance of considering other study designs in the challenging intensive care unit environment.

Also this: https://oxicmblog.wordpress.com/2016/01/30/critical-care-reviews-meeting-2016-blog-session-1-2/

 

[deleted171991]

From the brilliant Dr. John Hinds:

 

[deleted162650]

This is my favorite critique of EBM:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/pdf/32701459.pdf

 

[urge]

From the brilliant Dr. John Hinds:

I have 2 memorable difficult intubations from residency. In both the attending was applying ******ed levels of cricoid pressure. In one the attending let go and intubated himself and then told me he couldn't understand how I couldn't intubate because it was so easy. In the other it was the chairman who looked at me like a deer in the headlights when I could not get a good DL view during an emergency obstructed bowel case. I gave it a 2nd try with all my brute force and managed to get a view. A surgical resident bitched about how come I was having trouble when he was easily intubated recently. Must be me.

 

[Planktonmd]

Every stupid randomized study starts with a stupid hypothesis, and this is why no matter how good the investigation is if the hypothesis is stupid the result is guaranteed to be a pile of crap.
Under the pressure to publish something to achieve some academic advancement many of our esteemed academic colleagues start with any garbage hypothesis and end up with evidence based garbage.

 

[Onefellswoop87]

This is my favorite critique of EBM:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/pdf/32701459.pdf

You beat me to it. I love that article

 

[loveumms]

And remember. The human body is incredibly resilient and it's really hard to kill someone. Some scientists try harder hen others but luckily the most important part of medicine remains - the body is resilient (and can luckily withstand some really crazy RCTs).

 

[KLPM]

http://www.ncbi.nlm.nih.gov/pubmed/26711672

This is evidence-based medicine.

Jack Iwashyna trying to explain why the EBM community need to re-think RCTs:

 

[Urzuz]

We consider them advances, except that there is more and more contradicting evidence for each of your examples.

EGDT is half-dead, at least in the Manny Rivers version. CVP, ScvO2, tons of fluids etc., all proven worthless. Therapeutic hypothermia is proven again and again to be worthless. The main "proven" benefit is after ventricular arrhythmia leading to arrest, and even that one is debated. Same goes for CPR as it is taught. There is more and more debate that the way we are doing CPR is bad (mechanically). Not only that, but basic tenets such as "no/minimal interruptions" are very debatable.

There are always going to be advances in treatments such that older ways of doing things become obsolete. But EBM is the tool we have to measure those changes and advancements.

When EGDT and the whole Surviving Sepsis Campaign was first widely adopted in their original form, I can guarantee you that they saved countless lives and improved outcomes across the world. Whether the improvement in outcomes was because of what Rivers described (optimizing patients' physiology) versus simply protocolizing a way of treating septic patients so the more "cowboy" and less-informed physicians didn't screw up treatment plans...that is up for debate. But now that most physicians' standard practice has evolved to include important elements of Surviving Sepsis and EGDT (even the cowboys and those graduating at the bottom of their residency class have probably picked up most of the important elements, such as giving antibiotics early), maybe those guidelines in their original forms deserve to get scrapped. And that is okay. They served their purpose for the time, and now that we've extracted the important elements from them, we can move on to the next big advancement. Same thing goes for ACLS and every other big advancement in EBM.

I agree that EBM has its issues, and that publication pressure all too often supersedes quality. That being said, EBM is crucial to how physicians disseminate their experiences and how medicine continues to advance itself. It ends up falling on the reader to critically evaluate the quality of the evidence, which is SUCH an important skill. Too many physicians (including a number on here) will believe anything as long as its on Pubmed and has been printed. This is naivety through and through, and is no better than soccer moms posting their own "evidence" on how vaccines cause autism " 'cuz Jenny McCarthy said so."

 

[deleted171991]

There are always going to be advances in treatments such that older ways of doing things become obsolete. But EBM is the tool we have to measure those changes and advancements.

When EGDT and the whole Surviving Sepsis Campaign was first widely adopted in their original form, I can guarantee you that they saved countless lives and improved outcomes across the world. Whether the improvement in outcomes was because of what Rivers described (optimizing patients' physiology) versus simply protocolizing a way of treating septic patients so the more "cowboy" and less-informed physicians didn't screw up treatment plans...that is up for debate. But now that most physicians' standard practice has evolved to include important elements of Surviving Sepsis and EGDT (even the cowboys and those graduating at the bottom of their residency class have probably picked up most of the important elements, such as giving antibiotics early), maybe those guidelines in their original forms deserve to get scrapped. And that is okay. They served their purpose for the time, and now that we've extracted the important elements from them, we can move on to the next big advancement. Same thing goes for ACLS and every other big advancement in EBM.

I agree that EBM has its issues, and that publication pressure all too often supersedes quality. That being said, EBM is crucial to how physicians disseminate their experiences and how medicine continues to advance itself. It ends up falling on the reader to critically evaluate the quality of the evidence, which is SUCH an important skill. Too many physicians (including a number on here) will believe anything as long as its on Pubmed and has been printed. This is naivety through and through, and is no better than soccer moms posting their own "evidence" on how vaccines cause autism " 'cuz Jenny McCarthy said so."

The problem is exactly what you say in the last paragraph.

For example, despite the fact that CVP and ScvO2 have been proven not to correlate with outcomes, despite the fact that the PAC has been proven repeatedly to cause more problems than it solves, despite the fact that the literature is full of studies suggesting that less fluids and early vasopressors are better, despite the fact that the same literature suggests, logically, that there is no sense giving fluids where they don't increase cardiac output, despite the fact that few measurements correlate well with that increase, I see uninformed (would almost say uneducated) doctors applying EGDT day in and day out, flooding patients with fluids. Even the current Surviving Sepsis Campaign guidelines are not rooted only in evidence, but also in tradition. Speaking about tradition, one has to point out how internists keep giving abnormal saline all around the country, when all evidence points against it. Same goes for not understanding SIRS, the great plague of this century. It doesn't mean sepsis in 50% of the cases, but a lot of people get agitated when they diagnose it. I have been called for "SIRS" in anemic elderly patients who were tachycardic, hypotensive and had cold extremities. And the list goes on. "EBM" and its algorithms probably kill as many patients as it save, by having them undergo unnecessary/wrong treatments and procedures.

Doctors generally suck at math, as a group, so why let them interpret statistical conclusions in the first place? Letting them play EBM, when they have no friggin idea what's statistically correct and what is not, is like letting children play with guns or decide world politics.

 

[Urzuz]

The problem is exactly what you say in the last paragraph.

For example, despite the fact that CVP and ScvO2 have been proven not to correlate with outcomes, despite the fact that the PAC has been proven repeatedly to cause more problems than it solves, despite the fact that the literature is full of studies suggesting that less fluids and early vasopressors are better, despite the fact that the same literature suggests, logically, that there is no sense giving fluids where they don't increase cardiac output, despite the fact that few measurements correlate well with that increase, I see uninformed (would almost say uneducated) doctors applying EGDT day in and day out, flooding patients with fluids. Even the current Surviving Sepsis Campaign guidelines are not rooted only in evidence, but also in tradition. Speaking about tradition, one has to point out how internists keep giving abnormal saline all around the country, when all evidence points against it. Same goes for not understanding SIRS, the great plague of this century. It doesn't mean sepsis in 50% of the cases, but a lot of people get agitated when they diagnose it. I have been called for "SIRS" in anemic elderly patients who were tachycardic, hypotensive and had cold extremities. And the list goes on. "EBM" and its algorithms probably kill as many patients as it save, by having them undergo unnecessary/wrong treatments and procedures.

Doctors generally suck at math, as a group, so why let them interpret statistical conclusions in the first place? Letting them play EBM, when they have no friggin idea what's statistically correct and what is not, is like letting children play with guns or decide world politics.

Agree with what you say above. It is sad, as the onus is on physicians to stay informed of the current literature and be critical, adaptable, and intelligent enough to evaluate guidelines and take them for exactly that...GUIDELINES, not mandatory "must-dos." This is exactly why medicine requires bright minds and hard working people who will dedicate their lives to their work and not simply earn then MD then continue practicing the same way for 30 years, unnecessarily executing countless patients in their path because they did not stay current. The situation will only compound itself and get exponentially worse as "advanced care practitioners" start getting behind the helm of patient care. It also doesn't help that nurses with clipboards will evaluate how "good" or "bad" of a physician someone is based on how closely, down to a letter, a physician followed their guidelines.

I completely agree that this is a huge problem with EBM, and it's sad. In some ways it's akin to gun control -- guns themselves aren't inherently bad since they are just tools. The responsibility falls on gun owners to be intelligent enough to use that tool in a safe, judicious manner. However, we all know that certain people never deserved to be gun owners to begin with since they aren't able to assume such responsibility. Guns as a whole then get condemned as being bad, when in reality it's the irresponsible gun owners that ruined it for everyone.