The Fatal Failings of Evidence Based Medicine

I agree with Dr Hunt that EBM is often misused by payors and regulators to have leverage over doctors and their patients. However, this is not an inherent flaw in EBM but rather a flaw in the way that we as doctors and citizens allow third parties to dictate the care of patients. EBM is just a tool--it would be silly to say a hammer is bad just because an incompetent carpenter used it to build a house that fell down.

To me the bigger problem/obstacle with EBM is access to the evidence: individual doctors are expected by the ivory tower and payors to be "up to date" and research all of their care decisions in the literature. The problem with this is that the academic publishing cartel demands subscription fees of $400 per journal from every doctor who is not in an academic center with library access. To even subscribe to the handful of highest impact-factor journals in one specific specialty is a proposition of several thousand dollars per year!
 
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Whenever coercion is used for ANY purpose, it causes things to go awry, because it is immoral. EBM has been coopted by the forcers and defrauders as a tool, and it is in that setting that EBM sucks. Remove the force and fraud and EBM can compete with other types of thinking for the hearts and minds of doctors and patients.
 
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I love the concluding paragraph that the best care will basically be a well-reasoned combination of evidenced-based medicine and patient-based medicine. I have seen this work in PT too, it is not just a medicine issue. The top-notch PTs I have seen start of therapy with their "best guess", so to speak, of what a person will benefit most from, and this is often based on evidence/what's in the literature. But PT is great because you can see from session to session over the course of weeks how a person is responding, and modify treatments based on "anecdotal" evidence or your own experience as needed.

I think understanding the concept that the overall conclusion of this article is trying to make is one thing that will separate good healthcare providers from great ones in the years to come.
 
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The author lost me when he completely incorrectly claimed fascism on something that 1) has little to no commonality to any fascist tendencies and 2) was completely unnecessary to have an aside on.

It's a shame that he wishes to bring unrelated fears of government and oversight into am article that could have been much more thought provoking had he not dove head first into highly subjective criticisms, rather than the objective concerns he only superficially addresses.

EBM is saving lives. Period. It saves lives. But there are lives (and limbs) lost because the EBM approach is sometimes inappropriate for the specifics of the patient. Following the evidence will save more lives than it costs and save many more than anecdotal medicine alone would. But a discussion of the flaws of never fine tuning an approach to your patient would have been brilliant.

A discussion of how evil the government and pharmacy industry is... Well, it was less impressive and diluted the excellent points about the blind adherence to protocol. There is a place to criticize pharmacy influence. I believe it's massively overstated by most, but there is a place for that discussion. Having it under the guise of EBM criticism only serves to poison young minds against one of the most vital life saving methods we have. Especially if the criticism is highly subjective and largely based on presumptions about what might/could be happening rather than objectively known occurrences. (Not that it's wrong necessarily, only that those concerns are not evidence based themselves)
 
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if we don't recognize fascism when it rears part of its ugly head, we won't be wise enough to battle it. Compulsion of whatever the government wants done is part of fascism. Collectivization, followed by collaboration between collectivized groups (companies/unions/associations/races) and the government to disempower the individual is a hallmark of fascism. Absence of hypernationalism does not mean that the other fascist features are not present.

Inciting fear of government intrusion and regulation into medical care requires no effort other than suggesting people open their eyes and use their rational brain. Well, that's not quite right. Those whose ideology allows and encourages the use of force against their fellow man will always be willing to force their will on others.
 
Eddie Marcus: if we don't recognize fascism when it rears part of its ugly head, we won't be wise enough to battle it. Compulsion of whatever the government wants done is part of fascism. (it's not. I'm curious what you're thinking of) Collectivization,(no. You're thinking nationalization, which is a part of fascism and is very different) followed by collaboration between collectivized groups (almost explicitly fascism is against this. It endorses the epitome of competition-to-the-death for groups and companies. Eliminating any company that can't keep up.) (companies/unions/associations/races) (while not a rule, fascism is pretty anti-union through nearly all of its history as a popular social construct. So mentioning them is misguided) and the government to disempower the individual is a hallmark of fascism (well there you are right). Absence of hypernationalism does not mean that the other fascist features are not present(but the abscence of *any* fascism features do. Fascism is hyper-capitalist with companies that fail being closed and companies that succeed are usually given lucrative financial incentives or contracts to keep them succeeding. There really is nothing about any of this that resembles fascisms social constructs, economic constructs, or general philosophy at all. Fascism can't be a catch all term for any government power.)

Inciting fear of government intrusion and regulation into medical care requires no effort other than suggesting people open their eyes and use their rational brain. Well, that's not quite right. Those whose ideology allows and encourages the use of force against their fellow man will always be willing to force their will on others. (I have no comment except to say that I think this is insanely off topic now, so I'll call it quits from here because I don't even know how to relate this back to the topic)
 
The topic from which the discussion arises (inappropriate use and abuse of Evidence Based Medicine in a command/control economy) is interesting, but the discussion of the nature of the health care system as a whole in this nation is more interesting perhaps.

What is our health care system then? Not socialist, (although partly it is). Certainly NOT free market (there is essentially no free market in medicine). Certainly NOT capitalist. Certainly NOT communist (we still have some property rights).

I fear there is confusion between Hitlerism and fascism being presented here. I am quite confident I know my terms and how I use them. And I am also confident that fascism as "hyper capitalist" is fallacious (I don't even know what "hypercapitalist" means--you mean like "hyper free"??) I have little doubt that the US educational system has no problem confusing the terminology to keep Americans all messed up in our thinking. There are so many wonderful definitions out there used against us. Our world is filled with Newspeak, and the Ministry of Truth is active. "Liberal" and "conservative" for example keep utterly reversing themselves, so that now (at least in an economic framework) "liberal" means the opposite of what Liberal really meant (it use to mean freedom, and now means control) . And the "Conservatives" (a word meaning 'slow to change') now want radical change.

One definition of fascism is "a government that thinks it has the authority to do anything that it decides needs to be done, without limitation by any law, nor paying any heed to the rights of individuals". It is not worth a battle over the various changing definitions of the words we use, because those definitions flip around all over the place. Our poor children are STILL taught in school that fascism and socialism are opposite sides of the political spectrum, when indeed they are actually very similar ("national socialism" was Hitlerism after all) with both being very much on the opposite side of the spectrum from "free-market capitalism". That's why Stalin and Hitler were the center of World War 2--they were the two bullies on the block, alike in most all ways, duking it out in their sociopathic maelstrom. Two command/control narcissistic sociopaths with nearly identical evil ideology were going to attack each other sooner or later.

How about another term for our medical system: "Crony-collectivism." Can you accept that one? That term is pretty accurate, and more appropriate than "crony-capitalism" (which is an internally contradictory phrase, as cronyism and capitalism are opposites. "Crony-corporatism" is a valid term for our medical system as well, except that so many people think "corporatism" means "Corporations", when actually is means "bodies or groups" and thus applies not only to formal corporations, but unions, associations (collectives), and other organizations.

None of the terms for our medical system are pleasant positive terms, like "free market", caring, patient centered, abundant, easy, etc....
 
Not biting any bait for a full debate, so ill try to be brief. But please realize nearly every European country had a period of fascism. (Well... Probably about 15 of them, but still). I also happen to come from the most recent "western" fascist countries. It is an extremely well defined set of beliefs and related economic practices (just like how republic's have nothing to do with capitalism, but nearly all republics are largely capitalist). You appear to have little to no grasp of what nearly all of the world would define as fascism and "fascist related" policies.

You clearly have a well developed idea of what you are referring to, and are consistent with it, but your nomenclature for it is incorrect. I'm being a stickler to request the right terms, but when you see the wrong terms causally thrown around, it detracts from my willingness to believe your points (and there is plenty of good in there to discuss)

Also I'm in no way saying your concerns are misplaced (sort of side stepping it, but I'd agree with you in about half of the points maybe a bit more), just saying that your verbiage undercuts your point. I would love to see more debate on the subject matter you brought up. It is a very rich discussion ground and it is *important* to medicine to have it. I'm just not particularly up for having it myself.
 
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The author is correct in stating the limitations of EBM as a cohort-based rather than individual-based translation of medical practice. The generalizability of any treatment is then subject to the heterogeneity of the disease process and characteristics of the cohort studied, as compared to the treatment population. Most anyone involved with quality and process improvement understands there needs to be a reasonable space for practice variation to accommodate individual-patient factors.

Clinical practice guidelines as a tool for knowledge translation are well-recognized as flawed, as most have become corrupted by professional and financial conflicts of interest. Unfortunately, these same powers that corrupt CPGs also have close relationships with payor sources and "quality" benchmarking agencies, and thus physicians are hemmed in providing cost-ineffective care that may, in many instances, be harmful to the individual patient despite its foundation in EBM.

There are some very smart people out there working to reward their companies or institutions at the expense of society and the practice of medicine – and they are far better funded than those who seek to protect it.
 
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I disagree with the author. I don't want patient-based Medicine. The people who use anecdotes are the doctors, not the researchers. If there are no studies on a treatment, then I don't want it. Period.

"Yet, EBM is highly abusable and therefore guidelines should be questioned and never mandated. "
Absolute garbage. If guidelines are abusable, then guidelines need to be improved, not reduced.

This article sounds like an attempt to get Medicine out of Science into an independent thing and I can tell you that that is a freaking terrible idea.
 
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