Aug 25, 2010
11
0
Status
Medical Student
We had a professor/physician tell us this during an ethics lecture on our newly undertaken "social obligation."
 

adaptation1

7+ Year Member
May 29, 2010
178
7
Status
"medicine is not a science." I've heard that line so many times after coming to medical school -- especially coming from the older, more experienced physicians. The younger physicians tend to act like medicine is completely evidence-based and scientific, however. I don't know either way.
 

lowbudget

Senior Member
7+ Year Member
15+ Year Member
Aug 4, 2003
1,378
22
Visit site
Status
"Medicine is not only a science" is probably how I would put it. There's more to it.
 

DeadCactus

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
Oct 28, 2006
2,600
684
Status
Resident [Any Field]
A lot of it isn't. A lot of it is just hypothesis, guesses based on what makes sense in the framework of scientific concepts with no experimental verification. Add in the difficulties of applying micro-scale or population-scale scientific principles to the individual and things become even cloudier.

Right now, the field is closer to cooking than science. You take some scientific principles, apply them the best you can and ultimately rely on a lot of trial and error to point you in the right direction.

The field is transitioning, but it's asinine to pretend clinicians are practicing 100% science when just about every disease process has "through mechanisms not full elucidated" somewhere in the description. A lot of what is done clinically has yet to be verified via studies and even the studies that have been done are still trickling their way down into practice...
 
Sep 5, 2010
43
0
Status
Medical Student
A lot of it isn't. A lot of it is just hypothesis, guesses based on what makes sense in the framework of scientific concepts with no experimental verification. Add in the difficulties of applying micro-scale or population-scale scientific principles to the individual and things become even cloudier.

Right now, the field is closer to cooking than science. You take some scientific principles, apply them the best you can and ultimately rely on a lot of trial and error to point you in the right direction.

The field is transitioning, but it's asinine to pretend clinicians are practicing 100% science when just about every disease process has "through mechanisms not full elucidated" somewhere in the description. A lot of what is done clinically has yet to be verified via studies and even the studies that have been done are still trickling their way down into practice...
I heard these things few times between different rotations, especially in medicine rotation. And I (respectfully) don't agree and understand the notion of the saying that medicine is not science." It is not "exact science," sure. But if one practices correctly (i.e. evidence-based medicine), it is still scientific.

To elaborate, we may not cure or "get it right" 100% of time, but it does not mean it is not science. It simply means we just don't know. But we still use (or at least should use) empirical treatment results, META analysis, statistic correlations, etc, to give best proven method possible for diagnostic workup and treatment modalities. That is all that can be done. Study the observations we can obtain, form an educated, reasonable hypothesis that is grounded on relatively well-grounded principles, try the hypothesis, then rinse and repeat. This is what science is.

I think what people more likely are saying is that science does not always gives us all the truth we want. But then, I knew I wasn't going to play god just because I would wear white coat even before going to med school. Sorry if I sound cynical, but from personal experience, the people who said (in my clerkships) that medicine is not an exact science also tended to be people who put overemphasis (and wasted lots of time and effort) on much less "scientific" issues like social and ethical issues of medicine.
 

muhali3

10+ Year Member
7+ Year Member
May 6, 2009
1,787
121
Status
Medical Student
Practicing medicine is much more than just knowing what to prescribe or what procedures to perform. I think that's what they mean. You are a physician, not a PhD (unless you're mudpud). Science is only a component of it. But some specialties (Rad Onc) emphasize evidence-based treatments more than others.
 
Dec 27, 2009
62
0
Status
Pre-Health (Field Undecided)
Last edited:

VoiceofReason

all i care about is money
10+ Year Member
7+ Year Member
Apr 23, 2006
1,264
36
New York
Status
Resident [Any Field]
ill save you all the trouble by pointing out that nothing will change even if you somehow conclusively prove that medicine is an art or medicine is a science
 

facetguy

10+ Year Member
7+ Year Member
Jan 10, 2008
3,581
10
Status
And don't forget to factor in the influences of outside interests (which usually come down to money), which can and do affect how medicine gets practiced every day.
 

Jrsharp70

...failure to communicate
Mar 26, 2010
124
0
Status
Medical Student
Deferoxamine: sweet argument. tOol

A lot of it isn't. A lot of it is just hypothesis, guesses based on what makes sense
Aaaaaaaaalmost got it... you just forgot the next few steps!

Here, I got you this cute diagram from an elementary school resource site!



Just because you are sometimes *wrong* doesn't make the process less scientific, it just means that your hypothesis was based on incomplete information. Personal experience adds information (as does the experience of others, i.e. Pubmed)

Every win, loss, mistake, outcome, trial, error and decision in medicine can fit into this neat little chart.

Edit: taste is subjective, dead is not. Cooking reference = denied.
 
Last edited:

DeadCactus

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
Oct 28, 2006
2,600
684
Status
Resident [Any Field]
I heard these things few times between different rotations, especially in medicine rotation. And I (respectfully) don't agree and understand the notion of the saying that medicine is not science." It is not "exact science," sure. But if one practices correctly (i.e. evidence-based medicine), it is still scientific.

To elaborate, we may not cure or "get it right" 100% of time, but it does not mean it is not science. It simply means we just don't know. But we still use (or at least should use) empirical treatment results, META analysis, statistic correlations, etc, to give best proven method possible for diagnostic workup and treatment modalities. That is all that can be done. Study the observations we can obtain, form an educated, reasonable hypothesis that is grounded on relatively well-grounded principles, try the hypothesis, then rinse and repeat. This is what science is.

I think what people more likely are saying is that science does not always gives us all the truth we want. But then, I knew I wasn't going to play god just because I would wear white coat even before going to med school. Sorry if I sound cynical, but from personal experience, the people who said (in my clerkships) that medicine is not an exact science also tended to be people who put overemphasis (and wasted lots of time and effort) on much less "scientific" issues like social and ethical issues of medicine.
I agree with you. The point is simply that EBM is a relatively new iteration of medicine. We're still at a point where a lot of medicine has not been evaluated under the lens of the scientific process and is simply practiced out of seeming reasonable, having a historical tradition, and providing anecdotal evidence of success. Medicine is moving steadily toward being a science, but the field is not fully there yet.

Aaaaaaaaalmost got it... you just forgot the next few steps!

Here, I got you this cute diagram from an elementary school resource site!

Just because you are sometimes *wrong* doesn't make the process less scientific, it just means that your hypothesis was based on incomplete information. Personal experience adds information (as does the experience of others, i.e. Pubmed)

Every win, loss, mistake, outcome, trial, error and decision in medicine can fit into this neat little chart.
You have to test the hypothesis for it to be scientific method. Which was the point. A lot of medical practice is based simply on a mix of tradition and what sounds reasonable.

I'm sorry, I can't find a cute chart to break it down for you. Just re-read it a few times very slowly...
 
Last edited:

unsung

10+ Year Member
Mar 12, 2007
1,356
13
Status
Resident [Any Field]
I agree with you. The point is simply that EBM is a relatively new iteration of medicine. We're still at a point where a lot of medicine has not been evaluated under the lens of the scientific process and is simply practiced out of seeming reasonable, having a historical tradition, and providing anecdotal evidence of success. Medicine is moving steadily toward being a science, but the field is not fully there yet.



You have to test the hypothesis for it to be scientific method. Which was the point. A lot of medical practice is based simply on a mix of tradition and what sounds reasonable.

I'm sorry, I can't find a cute chart to break it down for you. Just re-read it a few times very slowly...
This is exactly right. Which is why I want to pull out my hair when people pretend something like acupuncture is THAT much different from *some* medical practices in western medicine (which are mostly due to historical tradition & empiricism).

Fact of the matter is, people experimented with little needles and found it worked for some stuff. Same thing for herbal medicines (think about Ephedra, which came from a traditional Chinese med).

It's all nice and good that western med is able to take some of those empirical findings and find the theoretical basis behind them, allowing them to be more precisely applied.

But let's not ignore the huge parts of medicine that are NOT evidence-based.

Ex 1: doc prescribes antibiotics for a kid with otitis media with effusion (NOT purulent, i.e. not an acute bacterial otitis media), even though the studies suggest he's not supposed to do it.

Why? I'm sure he's got his reasons... maybe the parents wouldn't be that happen with the doc if he didn't give'em out, perhaps... but point is, he's not "going by the science".

Ex 2: recent study shows that you're supposed to test shoulder ABductor mm strength a certain way... but our sports med prof specifically told us NOT to do it that way 'cuz the old docs don't do it that way, and we'll look like tools if we do it the new (and better) way.

All in all, a lot of "real life" clinical medicine isn't nearly as evidence-based as it purports to be. I only wish docs would actually acknowledge this, rather than hold on to their sense of superiority.
 

Jrsharp70

...failure to communicate
Mar 26, 2010
124
0
Status
Medical Student
You have to test the hypothesis for it to be scientific method. Which was the point. A lot of medical practice is based simply on a mix of tradition and what sounds reasonable.

I'm sorry, I can't find a cute chart to break it down for you. Just re-read it a few times very slowly...
What gives the impression of something "sounding reasonable"? Evidence. Every individual who has been shown (in vivo, in vitro, post-mortem) to have a condition has contributed to our knowledge. Your evidence is in front of you, in the patient, and behind you in the literature and lessons of every other patient who has ever had this condition.

The part that makes practitioners who they are is the same thing that makes architects who they are. It is that, often times, the "test"is the final product. Sometimes you only get one chance to build a structure that won't fall. But it doesn't mean that you don't still evaluate and draw conclusions. It is still a test of the theory.

CONCESSION: You ARE correct in an aspect you didn't mean to imply. All sarcasm and rudeness (on my part) aside. Much like architecture, the employment is somewhat artful. How you employ your knowledge is often a creative process. Also, getting your patient to elucidate all available information is an artful skill set.

But make no mistake, I am correct. You cannot give me a situation in medicine, even a creative application of medicine, that does not fit into the scientific method.
 

Jrsharp70

...failure to communicate
Mar 26, 2010
124
0
Status
Medical Student
But let's not ignore the huge parts of medicine that are NOT evidence-based.

Ex 1: doc prescribes antibiotics for a kid with otitis media with effusion (NOT purulent, i.e. not an acute bacterial otitis media), even though the studies suggest he's not supposed to do it.

Why? I'm sure he's got his reasons... maybe the parents wouldn't be that happen with the doc if he didn't give'em out, perhaps... but point is, he's not "going by the science".

Ex 2: recent study shows that you're supposed to test shoulder ABductor mm strength a certain way... but our sports med prof specifically told us NOT to do it that way 'cuz the old docs don't do it that way, and we'll look like tools if we do it the new (and better) way.
1) Doing something irrational with potentially harmful side-effects (bacterial resistance, or the risk inherent with any/every medical procedure) in spite of one's best knowledge is wrong. Period.

2) Not doing something to the best of one's ability, based on tradition, is unbecoming a human being. The old docs may have "evidence" that the new way is invalid. It is up to your mind to decide if their reasoning is sound.

You have just listed two very poor examples of exercising judgment and principles.
 

unsung

10+ Year Member
Mar 12, 2007
1,356
13
Status
Resident [Any Field]
1) Doing something irrational with potentially harmful side-effects (bacterial resistance, or the risk inherent with any/every medical procedure) in spite of one's best knowledge is wrong. Period.

2) Not doing something to the best of one's ability, based on tradition, is unbecoming a human being. The old docs may have "evidence" that the new way is invalid. It is up to your mind to decide if their reasoning is sound.

You have just listed two very poor examples of exercising judgment and principles.
Dude, I'm not condoning what they're doing in any way. I'm just giving examples of things that happen out in the "real world"... i.e. clinical practice. If you think things like this don't happen pretty much every day, then I don't know what to tell you.

Re 2), the "new way" IS the better way (I'm just going by what the prof taught to us)... however, the prof also acknowledged that no one does it by the new way; thus, he advised us to do what everyone else does, so as not to look like a "tool". (Btw, the new way is more accurate- thus better- way of doing it. However, obviously the old way still works well enough, hence people use it.) But the real point here is- people don't always go by what the science says... you might reason that people want to do things the "best" or most accurate way... and you'd be wrong.

People are intractable, stubborn, mercurial creatures. lol

Edit: Again, not condoning these particular examples. But in defense of the docs... I think the real "operating principle" out in practice is-- don't do anything that would cause serious harm. Is short course of antibiotics going to harm the kid? (What if he does turn out to have a bacterial infection? Even tho' studies suggest he most likely does not...) But short of that, how much people actually follow evidence-based medicine so as to do things the "best" way (according to evidence-based med) is verrrry variable.
 

Jrsharp70

...failure to communicate
Mar 26, 2010
124
0
Status
Medical Student
Dude, I'm not condoning what they're doing in any way. I'm just giving examples of things that happen out in the "real world"... i.e. clinical practice. If you think things like this don't happen pretty much every day, then I don't know what to tell you.
I know man, it is difficult. We will all have to deal with this crap. I'm not bagging on you, but it is important that we share ideas and figure out WHO we are and what we will stand for.

The fact is, conforming to these practices IS condoning them. There is time to listen, to watch and see what the current standard is. Watch a doc do it the "old" way and then ask later why? Good etiquette. Give a patient something with a very low-risk of side effects to create a happy mindset that is more likely to foster healing? Go for it if that is your judgment. No qualms here.

But in the end, you will have to justify every action. YOU will have to deal with inconclusive results from a dated test. YOU will have to define your own integrity. Integrity is acting with the best of your knowledge towards the best outcome.

Edit: evidence based medicine is redundant. Non-evidence based medicine is an oxymoron.

The scientific method IS the road map for the best possible decision making. Maybe you can use it to convince your superiors of your case. If not, you must decide the limits to your integrity. In the case of a shoulder exam... low risk. But how do you act when the stakes are much higher?
 

BigRedBeta

Why am I in a handbasket?
10+ Year Member
Nov 1, 2007
1,423
819
Status
Attending Physician
While EBM is important, it has it's limits. Things that are not controversial or that have severe ethical issues will NEVER have evidence to support them. What parent is going to let their infant with meningitis undergo a randomized, double blinded, placebo controlled trial? Even performing comparative effectiveness trials in such a scenario is unlikely to clear an IRB approval. Is giving antibiotics the 'right' thing to do? The idea makes sense intuitively, but there are lots of things in medicine that when the trials are actually done that we find out we were doing more harm than good - for example giving blood transfusions to patients who are anemic when their hemoglobin is 10 rather than 7. (FYI, I'm not arguing that we need to test antibiotic use in meningitis, just using it as an example in which we'll never have the evidence needed to practice evidenced based medicine).

The art is easily more appreciable in things like controlling pain. I use morphine and Fentanyl and oxycodone as my pain relievers of choice, but it's not wrong if someone else uses morphine, hydrocodone, hydromorphone and tramadol. Both methods are likely to work, and by using the same drugs consistently, it's safer for my patients - I know immediately if a drug dose is high on my go to meds, but have to look up the doses of the others...

Further, there are conditions like autism and developmental delays where treatment is not so simple as just giving a medicine, and where bias is inherent to the process because speech, occupational, physical and play therapies can't be blinded.

These are just a few examples. As the next generation of physicians, the responsibility is to use EBM where it applies, where the studies are well designed and broadly applicable and the recommendations are in line with our patient's wishes (when reasonable).
 

DeadCactus

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
Oct 28, 2006
2,600
684
Status
Resident [Any Field]
What gives the impression of something "sounding reasonable"? Evidence. Every individual who has been shown (in vivo, in vitro, post-mortem) to have a condition has contributed to our knowledge. Your evidence is in front of you, in the patient, and behind you in the literature and lessons of every other patient who has ever had this condition.

The part that makes practitioners who they are is the same thing that makes architects who they are. It is that, often times, the "test"is the final product. Sometimes you only get one chance to build a structure that won't fall. But it doesn't mean that you don't still evaluate and draw conclusions. It is still a test of the theory.

CONCESSION: You ARE correct in an aspect you didn't mean to imply. All sarcasm and rudeness (on my part) aside. Much like architecture, the employment is somewhat artful. How you employ your knowledge is often a creative process. Also, getting your patient to elucidate all available information is an artful skill set.

But make no mistake, I am correct. You cannot give me a situation in medicine, even a creative application of medicine, that does not fit into the scientific method.
Oh, I get it. You don't understand the difference between Evidence Based Medicine and science.

Yes, anecdotes and experience can constitute evidence. But if we revisit that cute chart of yours, we'll see those two steps about designing an experiment to test a hypothesis and conducting an appropriate analysis.

Just doing something and seeing what happens does not constitute science. Well, maybe bad science. But then we might as well lump medicine in with alternative medicine and just forget having any conversation of merit.

Let's take a look at EBM:

Level I: Evidence obtained from at least one properly designed randomized controlled trial.
Level II-1: Evidence obtained from well-designed controlled trials without randomization.
Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Level I and II fall into the realm of scientific medicine. Level III falls into the range of evidence, but not science. Level III is the land the hypothesis, that has yet to go through a well-designed experiment. The land, if medicine is entirely scientifically based, that doesn't exist. And yet it has it's own category at the base of the pyramid in the EBM guidelines.

If you really want to argue that medicine is entirely scientifically based when the profession is still working to get people on the EBM boat, well then good luck to you.
 

Jrsharp70

...failure to communicate
Mar 26, 2010
124
0
Status
Medical Student
I'll ignore Beta's post for now, because... I guess because it is less well stated.

Oh, I get it. You don't understand the difference between Evidence Based Medicine and science.
Burn...
Ok, I admitted my rudeness, but I can take a shot back while holding a white flag. Damn you for making me go back to my EBM powerpoints...

How about definitions? Since you like to play semantics...

Science:
systematic knowledge of the physical or material world gained through observation and experimentation.

EBM

"Evidence-Based Medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." (David Sackett, M.D., 1996)

And we'll even throw in a hierarchy of evidence:

Meta-analyses of randomized trials
Randomized controlled trials
Systematic reviews of observational studies
Observational studies
Physiologic studies
Unsystematic clinical observations

I used a (cute) chart that didn't go into enough depth, and I relied on others to fill in the blanks. I don't really know how else to interpret your response.

Here it goes. Every paper, every case report, every encounter builds a database in your mind/resource library. Patient presents will illness X:
Question: what is problem
Research: What do I know? What do others know? What is most reliable and if there are contradictions, why?
Hypothesis: patient can be treated by X, based on available information. What YOU know is not the extent of information available. Your case may not fit any specific case. You use YOUR BRAIN to apply relevant information, using the most reliable sources possible. If no case presentations fit exactly, then you must be the gatekeeper of applicable information. (And your peers' opinions are science, see: observation, above. You have the ability to evaluate their input. It is information that can be tested. Their reasons for telling you things have to have validity and testability)
Test: Read: act on hypothesis. I don't mean put a sick person in a trial, for the love of baby jesus. I mean freakin' treat them. The purpose of a hypothesis is to not waste time on the wrong experiments! You already have a pretty good idea, you just need to prove it.
Analyze: Live/dead is usually a good analysis, but obviously more info is tracked than that...
Conclusions: That information is forever retained. You were right or wrong. Wrong and not dead? Try again. Wrong and dead? Do better next time. Right? Don't stop incorporating new information just because you got it right this way, but for now, small victory.

Your information spreads. You write about it, others use it. It becomes their evidence. If it doesn't warrant a clinical trial by others, then YOU become next in line in the evidence chain.

I cannot be any more simple than that. I can't tell any better how research, hypothesis, testing, analyzing and concluding is science. Evidence is the basis for science, and every decision is inherently based on evidence towards the desired outcome. EBM is simply how we teach new doctors to hone their decision making skills.

If you don't get it, then I can't give it to you.
 
Last edited:
2

235009

definitely didn't read the whole thread but here is my contribution to this discussion (assuming it hasn't degenerated by now)

the patient consent forms at this hospital say "the practice of medicine is not an exact science" ...i think that's an accurate way of putting it
 

Bernoull

10+ Year Member
7+ Year Member
Mar 24, 2007
1,724
8
Ischioanal fossa
Status
Resident [Any Field]
Interesting discussion..

Even more fundamentally, not all RCT themselves are created equal.... There's a lot of junk/suspects RCTs (ridiculous assumptions, per-protocol analysis, subgroup analysis, cherry-picking statistical tests etc) that make it to publication in respectable journals... and meta-analysis of junk will spit out junk....

It's one thing if all the peer-reviewed literature is statistically sound, clinically relevant and conclusions adequately supported... but that's not always the case, so one should take a step back and critique the literature b4 taking it as gospel and I'm not sure if many practicing physicians do that...

More generally, I think there's no question whether the foundation of medicine is scientific, but out in practice, i think most things tend to lie in the "proverbial gray zone" and clinical experience/expertise and judgment is brought to bear constantly. That part I see more of as an art...
 

Jrsharp70

...failure to communicate
Mar 26, 2010
124
0
Status
Medical Student
Are there other things to do on the internet? :p

Well, besides porn...

Porn... on the internet... right. Next thing you'll tell me is that there is an aggregation of free encyclopedic knowledge of any topic built into a user contributed site that could answer my study questions simply by typing a keyword into a search box.

You guys think I am soooo gullible...
 

Jrsharp70

...failure to communicate
Mar 26, 2010
124
0
Status
Medical Student
OP
S
Aug 25, 2010
11
0
Status
Medical Student
FYI she was talking more about physician authority and duty than the day to day aspects of the work. Of course most of medicine is the use of skills and application of applied knowledge. The question in this lecture wasn't how to classify medicine but where it derives its authority, and therefore who decides how much freedom it has, if any.

Her reasoning behind "medicine is not a science" seemed to be that physician authority is derived from society's decision to empower us through licensing and education funding. We, then, owe society back...and the implication was that we have no inherent authority.

That is not true though, because medicine was founded on reason and science. This was the original source of physician authority. Once the scientific benefits of medicine became apparent, and in more demand, then and only then was it turned into a "social obligation."

To give you an idea of the road she was going down, she was sure to mention the Health Care Personnel Delivery System, also known as the "Doctor Draft."
 

gravitywave

fourth year
Dec 19, 2009
2,078
9
s/p ERAS
Status
Medical Student
I'll ignore Beta's post for now, because... I guess because it is less well stated.
...which was a mistake, as Beta's post was the one in the thread that you needed most badly to address. It stated quite well some of the problems with your position when it meets medicine as it is actually practiced. Beta is also a resident. Hmmmm.... :rolleyes:

Have you ever even seen the literature most doctors use to make everyday clinical decisions? Hint: it's not in a scientific journal. It's in places like UpToDate or trade journals, where there are so many references to "consensus, disease-oriented evidence, usual practice, expert opinion, or case series" as the only support available for accepted medical treatments that it will make your little EBM world spin.

I'm guessing you must be MI/II, otherwise you'd have a little more of a clue. I'm all for EBM, but there are some parts of medicine for which it will never have more than a very limited scope.

FYI she was talking more about physician authority and duty than the day to day aspects of the work. Of course most of medicine is the use of skills and application of applied knowledge. The question in this lecture wasn't how to classify medicine but where it derives its authority, and therefore who decides how much freedom it has, if any.

Her reasoning behind "medicine is not a science" seemed to be that physician authority is derived from society's decision to empower us through licensing and education funding. We, then, owe society back...and the implication was that we have no inherent authority.

That is not true though, because medicine was founded on reason and science. This was the original source of physician authority. Once the scientific benefits of medicine became apparent, and in more demand, then and only then was it turned into a "social obligation."
her argument is bunk, but then so is your rebuttal.
 

Jrsharp70

...failure to communicate
Mar 26, 2010
124
0
Status
Medical Student
...which was a mistake, as Beta's post was the one in the thread that you needed most badly to address.
I'm guessing you must be MI/II, otherwise you'd have a little more of a clue. I'm all for EBM, but there are some parts of medicine for which it will never have more than a very limited scope.
Umm... we already moved on to porn...

But since you can't move on, we'll play with Beta's post!

While EBM is important, it has it's limits. Things that are not controversial or that have severe ethical issues will NEVER have evidence to support them.
The Heliocentric solar system is not controversial... it has plenty of evidence. Ice reduces inflammation... I'm pretty sure I can peruse a book real quickly and find some evidence for that too.
What parent is going to let their infant with meningitis undergo a randomized, double blinded, placebo controlled trial?
None. The EBM hierarchy is a guideline for BEST AVAILABLE information.
Even performing comparative effectiveness trials in such a scenario is unlikely to clear an IRB approval. Is giving antibiotics the 'right' thing to do? The idea makes sense intuitively, but there are lots of things in medicine that when the trials are actually done that we find out we were doing more harm than good - for example giving blood transfusions to patients who are anemic when their hemoglobin is 10 rather than 7. (FYI, I'm not arguing that we need to test antibiotic use in meningitis, just using it as an example in which we'll never have the evidence needed to practice evidenced based medicine). I.n.f.o.r.m.e.d. C.o.n.s.e.n.t. Oh, and the IRB and OHRP are designed to help weigh EVIDENCE to justify reasoning, to assess harm, and evaluate P.I. competency (again, based on the evidence presented.)

The art is easily more appreciable in things like controlling pain. I use morphine and Fentanyl and oxycodone as my pain relievers of choice, but it's not wrong if someone else uses morphine, hydrocodone, hydromorphone and tramadol. Both methods are likely to work, and by using the same drugs consistently, it's safer for my patients - I know immediately if a drug dose is high on my go to meds, but have to look up the doses of the others...
Then you have reasoning. All things being equal, it is ethical to reduce error as much as possible. It is not an art, repetition breeds competency. This argument is invalid.

Further, there are conditions like autism and developmental delays where treatment is not so simple as just giving a medicine, and where bias is inherent to the process because speech, occupational, physical and play therapies can't be blinded.
Where in this argument have you ruled out cohort studies, case studies and molecular biology research? If you use a therapy, don't you have a reason based on evidence? If you use a drug, do you have no justification? Wouldn't your patient also be contributing to statistical data?
These are just a few examples. As the next generation of physicians, the responsibility is to use EBM where it applies, where the studies are well designed and broadly applicable and the recommendations are in line with our patient's wishes (when reasonable).
I'm glad we agree.


Thanks GravityWave! Iceman, Cyclops and the rest of the X-Men area already in another forum battling other poorly reasoned arguments... activate your gravity powers so we can fly in and help them!