Another assault on Evidence-based medicine

Except this time it's from the right! Richard Dolinar of the Heartland Institute (a crank tank) writes in TCS Daily that evidence-based medicine (EBM) is bad for patients.

A new buzzword entered the medical lexicon in 1992 when the Evidence-Based Medicine Working Group published one of the first articles on the phenomenon in the Journal of the American Medical Association (JAMA). In the years since, the role that evidence-based medicine (EBM) plays in medical care has increased exponentially. Some now question whether it should play such a prominent role.

"[EBM is not] medicine based on evidence, but the equivalent in the field of medicine of a cult with its unique dogma, high priest ... and fervent disciples," says Dr. John Service, editor-in-chief of Endocrine Practice. Indeed, if a doctor questions EBM today, it seems he or she runs the risk of being branded an infidel or heretic, or worse.

Now there is a bad sign. When someone calls medicine a cult, you know you're about to hear some real nonsense, usually from an altie. But hey, I'll give them a chance. Why exactly is it that I'm supposedly studying to be a priest in this cult?

Proponents of EBM assume it will improve the quality of health care by basing medical decisions primarily on statistically valid clinical trials; therefore, information gained from randomized clinical trials (RCT) preempts information from all other sources. Yet, isn't it ironic that a review of the literature by this author and others turns up no evidence as defined by EBM to validate this assumption?

Holy FSM! He searched the entire medical literature and found that there aren't any articles scientifically showing that science works! Wait what? That can't be right.

"The failure to conduct a randomized controlled trial, the recognized best form of evidence according to EBM, and reliance on expert opinion, namely theirs (the worst form of evidence according to them), hoist EBM by its own petard," notes Service. EBM purports to provide "statistical proof" when in fact what it provides is "statistical data." Data does not necessarily equate to proof. Data is open to interpretation, which can change over time or vary depending upon one's perspective.

Page epistemiology! We have an emergency - our patient is having a crank attack! I guess they have a point, we're clearly ignoring all those other methods of acquiring medical knowledge besides the RCT. I mean, we don't really know they work. All they do is provide highly replicable data showing the efficacy of various medical interventions in different patient populations. That's just data, not "truth". Now divining, that must be how you find truth. I also think that he's not just being cranky, he's also just completely wrong. As I've pointed out many times John Ioannidis does just this kind of work (note the presentation, not the PLoS paper, is more relevant to RCTs).

It gets worse, and I mean, much much worse. And I'm left wondering what the hell kind of denialism the Heartland Institute is up to now?

Continued...

Dr. George Spaeth makes this point in evaluating the Ocular Hypertension Treatment Study, which involved more than 1,000 people who had increased intraocular pressure but no optic nerve damage or visual field loss. Only 5 percent of those treated went on to develop visual field loss, whereas 10 percent of those not treated did.

This data can be used to argue either for or against treatment, Spaeth notes, depending on one's interpretation and incentives. The treating physician could argue that instituting early treatment would reduce visual field loss from glaucoma by 50 percent. Yet, a third-party payer with financial incentive could just as easily argue against treatment, noting that the overwhelming majority of patients with elevated intraocular pressure do not get worse, even when not treated. Consider the evidence. Who is right? They both are.

Is there, indeed, a best practice regarding the approach to elevated intraocular pressure? If so, how should the algorithm be constructed? Who should have the ultimate discretion in making that decision? Should it be the treating physician, with the best interest of the individual patient in mind? Or a third party with the best interest of the bottom line in mind?

I think I just lost my vision reading such a stupid argument. Prevention is wrong, according to this guy, because we don't know ahead of time if we will actually prevent the disease in any given patient! We, must protect the poor insurance companies from paying for preventative treatments because they may pay for stuff that won't prevent a specific disease from occurring 100% of the time! Really, what an incredible idiot. He actually has an MD and he's dismissing prevention!

Now, being way too fair to this guy, let's think about this from a purely economic standpoint, does he even have an argument there is an advantage for a third-party payer to avoid 5% of patients going blind? Hmmm. Cost of glaucoma drugs? Not much, maybe $25 a month. Cost of paying for nursing care, nursing homes, disability etc. for someone who has gone blind, especially as an older adult? Try well over a $1000-2000 per month conservatively. If you can prevent 1 in 20 patients from costing 100-200 times as much as the preventative therapy costs, isn't that a pretty good deal? The way I figure it, the first couple of people you prevent going blind pay for the rest getting the drugs.

And that's just the economic cost, doctors exist for a purpose other than creating the perfectly efficient libertarian utopia too. Doctors are patient advocates, not society's beancounter. It is simply not appropriate, and in this case downright ghoulish, to suggest that a doctor should look at a patient and decide whether something as important as their vision is worth 25 dollars a month to the patient's insurance company. Granted, at the extremes, economic decisions over limited resources have to be made, but that's like "who gets what organ", not "who gets a drug available for a dollar a day."

Finally, this suggests it's somehow a terrible imposition on the insurance company that a patient might expect his insurance (that he pays for) actually pay money when he gets sick, so a doctor can prevent something that might blind him!

Clinicians now fear medical malpractice suits if they do not follow EBM guidelines in treating patients. But as one resident recently asked me, which guidelines do you follow? Even guidelines about the same disease can vary substantially, depending upon which professional organization promulgated them.

This is also tremendously ignorant argument for a doctor to make. Doctors don't sit around frozen like Buridan's Ass trying to decide which of two equal stacks of hay is better. They have opinions and brains, and will make decisions they think are best, and as long as those decisions meet the standard of care, they'll be fine. Choosing between two guidelines is not some horrible difficulty we have to face and then get punished for. This is a total red herring.

What's more, by following them, don't we freeze medical practice in time? How is progress to be made in health care if we are forced to walk in lockstep with algorithms promulgated last year or the year before?

It is not the epidemiological data of EBM that I question, but rather the manner in which it is used to displace clinical judgment. The physician has taken the history, performed the physical, reviewed the labs, and discussed the illness with the patient and family. He knows the patient's wishes, desires, and values. All this critical information must be considered when treating patients.

EBM, by contrast, relies primarily on epidemiological data, which it uses in a way that preempts all other information

collected by the treating physician. In fact, non-quantifiable information such as the patient's values and the physician's clinical experience are not even taken into account in EBM.

That's right, because every doctor should experiment on every patient, that's how knowledge is obtained. This man is an MD and he doesn't understand how medical progress is made. Guidelines get updated based on progress in the medical literature. It's a little bit frightening really that he is suggesting that we make progress by individually tinkering with patients. Although individual physicians will rely on personal experience for their practice, and don't act like little EBM-robots, this is not the major source of medical innovation, it is too personally-biased and impossible to aggregate information to set standards for practice. Nor does EBM discount patient history, or family, and doctors have absolutely no problem balancing patient wishes, desires and values with EBM. It's pretty simple. The patient's wishes, desires and values pre-empt EBM when in conflict, unless you convince the patient otherwise. This is again a total red herring. There is no conflict here, the patient is in charge of their life, and don't have to accept any therapy they don't want, and any physician is perfectly capable of choosing any therapy they want, as long as it meets the standard of care. I've seen many instances in which doctors look at EBM recommendations and reject them based upon patient characteristics, but they have good reasons for doing so and the EBM is still informative most of the time.

What's even more frightening is this doc then jumps into the classic woomeister argument, that medicine is inadequately individualized:

"The result is form taking precedence over substance," says Service. In the process, it is often forgotten that a group's responses, as an aggregate, can be quite different from an individual's response to a specific therapy. Patients are individuals, not groups. When one treatment is shown to be better than another on a population basis, this does not necessarily mean that it is the best treatment for the patient.

So, what information should doctors use to decide instead? Their gut? A magic 8-ball? What is there, besides evidence, either from studies or clinical experience (which is not contraindicated by EBM) to decide from? What method does he have of identifying which patients get what treatments that is resistant to the scientific method? After all, if he has a new criteria he's discovered in his clinical experience, he's perfectly welcome to prove its efficacy scientifically, and then maybe we'll believe its something other than random chance or observer bias.

I'm not exactly sure what direction the Heartland institute, the right-wing anti-AGW crank tank, is taking this. What it sounds like is an objection to EBM that is expensive for insurance companies on the basis that making recommendations based on *gasp* clinical data is some kind of error. This is a pretty astonishing position for a doctor to take and I must admit some shock at seeing the same backwards arguments of the alties come out of an MDs mouth.

The fact is that EBM is a guide for doctors that is perfectly violable for good reasons. You will not lose your license for not following cookbook medicine, unless you do something really incompetent and stupid. I'm still confused about what the goal of this piece is though. No doctor has his or her hands tied by medical guidelines, they are free to violate them if they have a good reason to do so, but yes, if you kill your patient doing something contradicted by the data you might have to answer for it.

So what do other people think. What could possibly be the goal of attacking EBM, and medical practice based on clinical trials for the Heartland? I'd say shilling for insurance, but wouldn't it be worse for third party payers if they had to adjust to the arbitrary vicissitudes of every doctor and every patient?