Damn you PZ!
(Heh, I haven't gotten to say that since he shamed my profession by showing us an example of a certifiably loony young earth creationist physician running for Lt. Governor of South Carolina.)
This time around, I'm annoyed at PZ for pointing me in the direction of an article so absurd, so ridiculous, so full of postmodernistic appeals to other ways of knowing with respect to science that at first I thought that it had to be a parody of postmodernism in the form of, as PZ put it, suggesting that Foucault or Derrida should have as much value treating your cancer as evidence-based medicine. PZ happened to have found the article by way of Martin Rundkvist. (Martin is, by the way, a future host of the Skeptics' Circle; so I guess I can't come down too hard on him; that, however, doesn't let PZ, Ophelia, or Ben off the hook for subjecting me to this as I perused my blog list this morning.)
Why am I so irritated? Because of PZ's and other bloggers' pointing this out, I ended up reading this article:
I'm sure I lost thousands of neurons as a result, and I'm pissed. If I'm going to lose some neurons, I at least want it to be in the course of something pleasurable, such as quaffing several fine beers, rather than plowing through pseudointellectual tripe like this. Because of references to Mussulini, Hitler, and fascism, I came just this close to writing yet another Hitler Zombie piece about this thing, but then I decided that this wasn't even worthy of an appearance by the Undead Corporal FÃ¼hrer, as such an appearance would give this article more dignity than it deserves. Unfortunately, as ScienceBlogs' resident apologist for evidence-based medicine, I have little choice but to comment on this, as I'm sure it will be turning up on altie websites and on Usenet very soon. So, Holmes et al, you want to "deconstruct" evidence-based medicine (EBM)? There's only one response to that, and that's a little "deconstruction" of your article, done with Respectful Insolenceâ¢, of course?
So, let's start out with the abstract:
Background: Drawing on the work of the late French philosophers Deleuze and Guattari, the objective of this paper is to demonstrate that the evidence-based movement in the health sciences is outrageously exclusionary and dangerously normative with regards to scientific knowledge. As such, we assert that the evidence-based movement in health sciences constitutes a good example of microfascism at play in the contemporary scientific arena.
Objective: The philosophical work of Deleuze and Guattari proves to be useful in showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm - that of post-positivism - but also and foremost in showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure.
Conclusion: The Cochrane Group, among others, has created a hierarchy that has been endorsed by many academic institutions, and that serves to (re)produce the exclusion of certain forms of research. Because 'regimes of truth' such as the evidence-based movement currently enjoy a privileged status, scholars have not only a scientific duty, but also an ethical obligation to deconstruct these regimes of power.
Geez, I had no idea that the Cochrane Collaboration was so amazingly powerful. Perhaps we in medicine should put them right up there with the Masons and the Illuminati. In any case, I may not know much philosophy, but I know Grade A bullshit when I see it. Microfascist that I apparently am for liking science and evidence-based medicine, let's see if I can place my jackboot right on the throat of this thing, apply sufficient pressure to make it gasp for air, and then apply my fascistic truncheon liberally to its face, all the while resenting that the authors apparently didn't consider EBM enough of a threat to label it real fascism. (I'll leave it to the postmodernist authors of the paper to figure out whether I'm being metaphorical or not.) Because this article is such an incredibly--shall we say?--target rich environment, I'll have to confine my pummeling to a few choice bits, lest this deconstruction swell to proportions beyond even my usual long-windedness.
Basically, this entire article is a huge appeal to other ways of knowing, coupled with massive straw men arguments, with a few other logical fallacies sprinkled in liberally for seasoning. The article begins:
We can already hear the objections. The term fascism represents an emotionally charged concept in both the political and religious arenas; it is the ugliest expression of life in the 20th century. Although it is associated with specific political systems, this fascism of the masses, as was practised by Hitler and Mussolini, has today been replaced by a system of microfascisms - polymorphous intolerances that are revealed in more subtle ways. Consequently, although the majority of the current manifestations of fascism are less brutal, they are nevertheless more pernicious.
You can almost hear the authors rubbing their hands together and cackling at being so...contrary, so...naughty, so...against the old stodgy scientists who think that we can actually know or measure reality with something close to objectivity. In other words, they're just throwing in the comparison because it's inflammatory. They then state their objective:
Drawing in part on the work of the late French philosophers Deleuze and Guattari the objective of this paper is to demonstrate that the evidence-based movement in the health sciences is outrageously exclusionary and dangerously normative with regards to scientific knowledge. As such, we assert that the evidence-based movement in health sciences constitutes a good example of microfascism at play in the contemporary scientific arena.
Yes, I suppose that one would find EBM to be "outrageously exclusionary" if one is a quack. But let's get to the meat (or what passes for meat in this article). First, here's the straw man that the authors harp on over and over and over:
As a global term, EBHS (evidence-based health sciences) reflects clinical practice based on scientific inquiry. The premise is that if healthcare professionals perform an action, there should be evidence that the action will produce the desired outcomes. These outcomes are desirable because they are believed to be beneficial to patients. Evidence-based practice derives from the work of Archie Cochrane, who argued for randomised controlled trials (RCTs being the highest level of evidences) as a means of ensuring healthcare cost containment, among other reasons. In 1993, the Cochrane Collaboration, serving as an international research review board, was founded to provide clinicians with a resource aimed at increasing clinician-patient interaction time by facilitating clinicians' access to valid research. The Cochrane database was established to provide this resource, and it comprises a collection of articles that have been selected according to specific criteria. For example, one of the requirements of the Cochrane database is that acceptable research must be based on the RCT design; all other research, which constitutes 98% of the literature, is deemed scientifically imperfect.
Uh, no. Not exactly. While it is true that randomized clinical trials (preferably double-blinded) are considered a very high form of evidence; it does not follow that all other research is "scientifically imperfect," simply for the reason that RCTs are not considered "perfect." No science is, nor does the Cochrane Collaboration insist on or use only RCTs in formulating its literature reviews. True, there are some "true believers" who do push rigid EBM as a panacea, but they are definitely in the minority and tend to be viewed skeptically among most other EBM advocates. In any case, from the above, it's pretty clear that the authors have no clue what EBM really is, and they demonstrate further how little they understand as they continue:
Consequently, EBHS comes to be widely considered as the truth. When only one method of knowledge production is promoted and validated, the implication is that health sciences are gradually reduced to EBHS. Indeed, the legitimacy of health sciences knowledge that is not based on specific research designs comes to be questioned, if not dismissed altogether. In the starkest terms, we are currently witnessing the health sciences engaged in a strange process of eliminating some ways of knowing. EBHS becomes a 'regime of truth', as Foucault would say - a regimented and institutionalised version of 'truth'.
No, EBM does not--I repeat--does not represent itself, nor is it represented as the "truth," nor is the Cochrane Collaboration this big, monolithic organization that tries to control this "truth" (which is what the article doesn't just imply but almost comes right out and says explicitly--hence all the references to "fascism" and "microfascism"). This is what the Cochrane Collaboration is:
The Cochrane Collaboration is an international, non-profit, independent organisation, established to ensure that up-to-date, accurate information about the effects of healthcare interventions is readily available worldwide. It produces and disseminates systematic reviews of healthcare interventions, and promotes the search for evidence in the form of clinical trials and other studies of the effects of interventions.
And this is what it does:
The Cochrane Collaboration prepares Cochrane Reviews and aims to update them regularly with the latest scientific evidence. Members of the organisation (mostly volunteers) work together to provide evidence to help people make decisions about health care. Some people read the healthcare literature to find reports of randomised controlled trials; others find such reports by searching electronic databases; others prepare and update Cochrane Reviews based on the evidence found in these trials; others work to improve the methods used in Cochrane Reviews; others provide a vitally important consumer perspective; and others support the people doing these tasks.
Ooooh. Scary. Damn those Cochrane fascists! Clever little jackbooted brownshirts that they are, they've even coopted diversity:
The Cochrane Collaboration is committed to involving and supporting people of different skills and backgrounds, to reducing barriers to contributing, and to encouraging diversity. A document entitled 'Cross-cultural team working within The Cochrane Collaboration' gives advice on communicating with people from other cultures.
Even worse, they've published a document suggesting how to take into account other cultures and other ways of thinking. Will they stop at nothing?
The entire premise of this paper rests on a straw man, namely that the EBM as epitomized by the Cochrane Collaboration (which, when you come right down to it, is simply an organization that puts together reviews of the best current scientific evidence for and against various therapies) has some sort of over-reaching control over all of EBM and how medicine is practiced. In actuality, medicine would probably be better if the Cochrane Collaboration did have that kind of control, as far too much of medicine is still not as evidence-based. as it should be However, for all its faults, conventional medicine is certainly far more evidence-based than anything in "alternative" medicine, and that's a good thing. As for me, if we're talking about treatments that impact my health, I'd like to know what the evidence is that they actually work. Wouldn't you?
Instead of the parody of EBM that the authors of this utterly ridiculous article present, let's look at what EBM actually is:
Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.
Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.
Sounds dangerously fascistic, doesn't it?
And let's look at what EBM is not:
Evidence-based medicine is not "cook-book" medicine. Because it requires a bottom-up approach that integrates the best external evidence with individual clinical expertise and patient-choice, it cannot result in slavish, cook-book approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. Similarly, any external guideline must be integrated with individual clinical expertise in deciding whether and how it matches the patient's clinical state, predicament, and preferences, and thus whether it should be applied. Clinicians who fear top-down cook-books will find the advocates of evidence-based medicine joining them at the barricades.
Gee, this doesn't much sound like the "fascism" (or "microfascism") that the authors claim is at the root of EBM. Both clinical experience must be guided by the best available scientific and clinical evidence, but that doesn't mean that such evidence will devolve into "cookbook" medicine. True, we have developed a number of diagnostic and treatment algorithms from EBM, but these algorithms can never take into account the wide range of possible clinical presentations, and patient preferences must always be taken into account. It is also true that, in overzealous hands, EBM can come dangerously close to cookbook medicine, which would be a valid criticism. However, these authors have gone so over-the-top by labeling EBM as fascism that any hint of a reasonable critique of EBM has dissappeared in a cloud of postmodernist jargon and references to totalitarianism.
Evidence-based medicine is not cost-cutting medicine. Some fear that evidence-based medicine will be hijacked by purchasers and managers to cut the costs of health care. This would not only be a misuse of evidence-based medicine but suggests a fundamental misunderstanding of its financial consequences. Doctors practising evidence-based medicine will identify and apply the most efficacious interventions to maximise the quality and quantity of life for individual patients; this may raise rather than lower the cost of their care.
Indeed not. Let's say several RCTs suggest that, for instance, MRI is better for screening for breast cancer in certain populations than traditional mammography. That would very likely raise the cost of care, at least in the short run. There is also no guarantee that the money saved from the more cancers caught at an early stage would balance out with the cost of the far more expensive MRI as a screening test, which might mean that costs would rise in the long run as well.
But here's the biggest stompdown of this paper's intentionally constructed straw man of EBM:
Evidence-based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions. To find out about the accuracy of a diagnostic test, we need to find proper cross-sectional studies of patients clinically suspected of harbouring the relevant disorder, not a randomised trial. For a question about prognosis, we need proper follow-up studies of patients assembled at a uniform, early point in the clinical course of their disease. And sometimes the evidence we need will come from the basic sciences such as genetics or immunology. It is when asking questions about therapy that we should try to avoid the non-experimental approaches, since these routinely lead to false-positive conclusions about efficacy. Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the "gold standard" for judging whether a treatment does more good than harm. However, some questions about therapy do not require randomised trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient's predicament, we follow the trail to the next best external evidence and work from there.
This point is particularly relevant to doing clinical trials my specialty, surgery. Let's take an acutely hemorrhaging patient. It doesn't take an RCT to tell that taking the patient to the operating room to stop the hemorrhage will save the patient's life. Or consider appendicitis. It doesn't take an RCT to determine that removing the appendix in the case of acute appendicitis will result in far more people surviving than not operating. Indeed many surgical problems cannot easily be directly addressed by RCTs, at least not entirely ethically. For example, consider a test of doing a procedure versus not doing a procedure for a certain condition. It's impossible to blind the patients as to which group they are in, as one group would be getting an operation and the other wouldn't be. The only way you could truly blind the groups would be to do a sham operation on the control group--which leads to all sorts of ethical difficulties. Even then, the physicians would not be blinded to the treatment groups; they would know which patients got a real operation and which got a sham operation. (Even so, some groups have managed to do such trials.) Finally, there is the issue of operator skill; some surgeons are just better at some operations than others. If you're doing a randomized trial to compare one operation against another for the treatment of a disease, you can never be 100% sure that differences observed were due to differences in the operation or technical differences in the skills of the surgeons. That's why large numbers are often needed. The fact is, in surgery, much of the evidence upon which we base our clinical decisions does not come from classical double-blinded randomized studies. That does not make it any less evidence-based than medical oncology, where a great deal of the evidence comes from randomized, double blind, clinical trials, simply because it's much easier to do such trials when what is being compared are two different drugs, rather than two different operations. In all of these cases no trial can take into account the multiplicity of variables that can impact on any single patient. A clinician brings his or her skills and experience into the mix, particularly when the evidence from EBM is sketchy or conflicting.
What we're really looking at here, I must emphasize again, is an appeal to a different way of knowing:
We believe that health sciences ought to promote pluralism - the acceptance of multiple points of view. However, EBHS does not allow pluralism, unless that pluralism is engineered by the Cochrane hierarchy itself. Such a hegemony makes inevitable the further 'segmentation' of knowledge (i.e. disallowing multiple epistemologies), and further marginalise many forms of knowing/knowledge.
Ah, yes. "Pluralism." Whatever that means when it comes to scientific evidence. Does that mean that unscientific bunk like homeopathy should be considered as deserving of equal consideration as EBM, all in the name of "pluralism"? Personally, when it comes to pseudoscientific crap like this, EBM should be "outrageously exclusionary." However, even more than the "exclusionary" nature of EBM, what really seems really to bother the authors is the language of EBM and science, presumably because of its emphasis on evidence, reason, and fact:
We believe that EBM, which saturates health sciences discourses, constitutes an ossified language that maps the landscape of the professional disciplines as a whole. Accordingly, we believe that a postmodernist critique of this prevailing mode of thinking is indispensable. Those who are wedded to the idea of 'evidence' in the health sciences maintain what is essentially a Newtonian, mechanistic world view: they tend to believe that reality is objective, which is to say that it exists, 'out there', absolutely independent of the human observer, and of the observer's intentions and observations. They fondly point to 'facts', while they are forced to dismiss 'values' as somehow unscientific. For them, this reality (an ensemble of facts) corresponds to an objectively real and mechanical world. But this form of empiricism, we would argue, fetishises the object at the expense of the human subject, for whom this world has a vital significance and meaning in the first place. An evidence-based, empirical world view is dangerously reductive insofar as it negates the personal and interpersonal significance and meaning of a
world that is first and foremost a relational world, and not a fixed set of objects, partes extra partes.
This is simply the age-old complaint that modern medicine doesn't sufficiently value the humanity of the patient, that it's cold and uncaring, interested only in reason and science, a complaint that has been around ever since we first started to base medical practice on science rather than folklore. I applaud these postmodernist author, though, for showing admirable restraint in refraining from doing what I expected and mentioning Dr. Mengele as a natural consequence of the fascistic scientific world view in which an objective reality is acknowledged. Besides, the universe doesn't give a damn what we humans believe about it. Gravity will still cause you to tumble to the ground, whether you believe in it or not. Cancer cells don't pay attention to the observer's intentions and observations. Neither do microbes. As science has shown us, they do, however, pay attention to chemotherapeutics and antibiotics.
Indeed, the entire reason for the evolution of medicine from empirical, experience-based treatments to EBM comes from the very fact that the old ways were prone to a number of biases. The placebo effect guarantees that almost any intervention will make some proportion of patients with a given condition feel better, at least transiently. That's the main reason for double-blinding and randomization when possible. Many diseases are either self-limited or their course waxes and wanes. If a patient tries something (or a doctor tries something on a patient) right before the disease symptoms wane, he or she will likely falsely attribute the clinical improvement to whatever was done right before, even though the intervention may or may not have had anything to do with the patient's improvement! Confirmation bias means that, if you expect a treatment to work, your tendency, unintentional but real, will be to remember bits of evidence that fit with what you expect and to disregard or forget those that contradict what you expect. Because human observation is so fallable and so easily able to misrepresent objective reality is exactly what the scientific method corrects for. There are many other such pitfalls.
Here's where PZ thought that the authors started to make sense, and they do, sort of, but they also show just how little they understand what is and is not EBM:
Of course, we do not wish to deny the material and objective existence of the world, but would suggest, rather, that our relation to the world and to others is always mediated, never direct or wholly transparent. Indeed, the sociocultural forms of this mediation would play a large part in the way the world appears as full of significance. Empirical facts alone are quantities that eclipse our qualitative and vital being-in-the-world. For example, how should a woman assign meaning to the diagnosis she just received that, genetically, she has a 40% probability of developing breast cancer in her lifetime? What will this number mean in real terms, when she is asked to evaluate the meaning of such personal risk in the context of her entire life, a life whose value and duration are themselves impossible factors in the
EBM never claimed to tell a woman how to "assign meaning" to a diagnosis of a genetic mutation that predisposes her to breast cancer and gives her a 40% chance of developing it in her lifetime. That's not what it's designed to do, nor should it be. "Meaning" is something only humans can provide. What EBM does do is to provide this woman with the tools to help her to assign meaning to that diagnosis herself and to decide, with the help of her doctor, what to do about it! Let's say that EBM informs this woman that she has a 40% chance of developing breast cancer. Further, let's say that it ca also tell her that prophylactic bilateral mastectomies combined with removal of the ovaries can reduce her risk by 20-fold or more. Only this woman can decide how much her breasts and ovaries mean to her as a woman. Some women will opt for removing their breasts to prevent cancer, even though without the surgery they are still more likely than not to avoid cancer. Others will decide to take their chances, often because they don't want to alter their bodies. Without the information that EBM provides, the woman would likely never have the opportunity to weigh the risks and decide to act or not. She would simply either develop cancer or not and die of it or not. In this particular case, EBM is empowering, and a skillful clinician will take into account such a diagnosis in the context of the rest of the patient's life. In other words, taking into account the totality of the patient's life is not incompatible with EBM.
Basically, the entire article is, from start to finish, one long extended rant about the Man keeping down those "other ways of knowing" or (as the authors put it) other epistemologies. Just check out this hilarious penultimate paragraph if you don't believe me:
The evidence-based enterprise invented by the Cochrane Group has captivated our thinking for too long, creating for itself an enchanting image that reaches out to researchers and scholars. However, in the name of efficiency, effectiveness and convenience, it simplistically supplants all heterogeneous thinking with a singular and totalising ideology. The all-embracing economy of such ideology lends the Cochrane Group's disciples a profound sense of entitlement, what they take as a universal right to control the scientific agenda. By a so-called scientific consensus, this 'regime of truth' ostracises those with 'deviant' forms of knowledge, labelling them as rebels and rejecting their work as scientifically unsound. This reminds us of a famous statement by President George W Bush in light of the September 11 events: 'Either you are with us, or you are with the terrorists'. In the context of the EBM, this absolutely polarising world view resonates vividly: embrace the EBHS or else be condemned as recklessly non-scientific.
Uh, no. Not exactly. But nice try. The authors do, however, get points for not only mentioning Hitler and Mussolini at the beginning of the article, but George W. Bush at the end while throwing in digs at "disciples" of the discipline they detest. In particular, they get points for this amazingly over-the-top conclusion:
When the pluralism of free speech is extinguished, speech as such is no longer meaningful; what follows is terror, a totalitarian violence. We must resist the totalitarian program - a program that collapses words and things, a program that thwarts all invention, a program that robs us of justice, of our meaningful place in the world, and of the future that is ours to forge together. Paradoxically, perhaps, an honest plurality of voices will open up a space of freedom for the radical singularity of individual and disparate knowledge(s). The endeavour is always a risk, but such a risk is part of the human condition, and it is that without which there couldbe no human action and no science worthy of the name.
Help, help! I'm being repressed!
The sad thing is, the can be legitimate critiques of EBM, mainly that sometimes it can be too rigidly algorithm-based and does not account for all variables. EBM is also notoriously difficult to apply in psychiatry, as well. Unfortunately, the authors here equate the quite reasonable insistence at the heart of EBM on, wherever possible, objective evidence from basic science and clinical studies to support the treatments we as doctors recommend to our patients with fascism and totalitarianism, all using pseudointellectual jargon and postmodernist posturing. Using their "other ways of knowing" or other epistemologies, it would be difficult to determine what is and is not quackery in medicine. Of course, that's probably the point. In any case, just because EBM has shortcomings is not a reason to give a similar level of deference to non-evidence-based "other ways of knowing" as we give to EBM. For that to happen, these other ways of knowing would have to prove themselves to be at least close to being as predictive as EBM. They can't.
How this oddity ended up in the medical literature is puzzling, but maybe it shouldn't be. The International Journal of Evidence-based Healthcare is a rather obscure journal that, as far as I can tell, isn't even indexed by Medline. Perhaps the editors thought that a little controversy would get people to read their journal.
It worked, I suppose. However, to me provoking ridicule from the blogosphere and from physicians who try to practice evidence-based medicine (even when they don't even realize that that is what they are doing) is not a good way to build readership and credibility.
What really bugged me is that if it is an appeal for respect for different ways of knowing, why didn't they mention a single other different way of knowing?
Any journal not indexed by medline is suspect IMHO. There is a reason for it, often the reason is because it has a sham of a review board, publishes non IRB research, etc. Between that, the fact that I've never heard of the journal until today, and the fact that you just demolished this obvious tripe, I think I'll skip my subscription...
The core argument seems to be that to claim that one kind of knowledge is truth is a form of fascism. My experiential knowledge that the sun goes around the earth, therefore, must be treated equally with the claim that the earth goes around the sun. Otherwise, we'll just be giving in to those heliocentric fascists.
Am I overly worried about the spreading epidemic of insanity, irrationality, and 'magical thinking' that seems to be spreading? The worst examples are political, of course, more on the right, but on my side as well -- I recently saw, on a relatively sober liberal blog, a series of comments on the "liquid terror' plot, and better than half the commenters either were sure that it was a hoax, or only accepted it because it was the British that discovered it and not the Americans. And as for the right, what passes for respectability like Coulter, Malkin, the recent Cheney comments, etc, would have ANY TIME IN THE 20th Century put the speakers among the wildest fringe elements.
But it isn't just politics, as the drivel you deal with here demonstrates.
I want to quote from THE DAFFODIL AFFAIR, a wonderful book by Michael Innes. (It was written in 1942 and obviously refers to the War, and of course the comments are framed in a wild 'harum-scarum adventure story' -- as Innes described his own work.)
"There werew men who had attempted to make what is called a corner in some necessity of life -- say in wheat. But to this man had come the concept of making a corner in poison... [T]he plan was clear. It was as if in the fourth century of our era, watching the decline and fall of world order in the empire of Rome, some cunning man had concentrated in his own hands all the promising superstitions, the long-submerged and half-forgotten magical instruments of the twilight ages of the mind.
"And yet it was not quite like that; the conditions were different. Today order and science and the light of knowledge might go, but in the chaos there would remain a network of swift communications, a wilderness of still turning and pounding and shaping machines. The great presses would still revolve and the radios blare and whisper. Whole systems of mumbo-jumbo would spread with terrifying rapidity: already were not weird systems of prediction, grubbed up from the rubble of the dark ages, printed by the million every day? Grant but the initial collapse on which this bad man was counting, and the spread of sub-rational beliefs would be very swift. Power would go to him who had the most and likeliest instruments of superstition to hand...." (p 121-122 Penguin edition)
I love it when Orac invokes the Respectful Insolence. It's like when The Rock takes his armband off, you know it's on.
Funny how well-off Western academics like to critize the science-based medicine that keeps them alive. They remind me of the spoiled rich kids I knew at school who bashed their parents as bourgeois, while still demanding money from them. (I was from the working class and was grateful for any material contributions my parents could make.) They should be forced to live (or die) according to their stated positions. Don't call an ambulance for your cardiac arrest-get an altie to cure you.
No, no, Medline is not the be-all and end-all of science literature databases. I had a colleague chew me out a while back because I was teaching all the intro biology students how to use it, and wasn't giving any time to other dbs...and she showed me a whole bunch of respectable journals not referenced by Medline, mostly in ecology and botany. Medline is a good source for the biomedical set, but there's another world of biology out there that gets short shrift.
I'd agree with PZ that Medline is not the be-all and end-all of literature databases. However, this article did come from the Journal of Evidence-based Health Care, fer cryin' out loud. If it were a decent journal, there's no reason it shouldn't be indexed in Medline.
Is it just me, or does "microfascist" make anybody else think of a midget Hitler? Like Mini-Me with a moustache! Although, come to think of of, Mini-Me already looks a bit like midget Mussolini... Hm.
All this talk reminds me of the time I described Michael Moore as a "postmodern Leni Riefenstahl". But now as I'm learning more about what postmodernists actually believe, I'm not so sure I was being fair to Leni Riefenstahl...
Thank you Orac for this great smack down. I have been looking forward to it, since you promised the response on PZ's blog yesterday. As a clinical investigator who participates in RCTs, observational epidemiology, and systematic reviews (some with the much feared Cochrane group), I agree completely with you assessment of the mighty strengths of EBM. I also agree with you that EBM can be misapplied or applied so rigidily as to prevent the appropriate use of clinical expertise (this of course is no reason to avoid EBM).
My only very minor comment regards your statement that:
The fact is, in surgery, much of the evidence upon which we base our clinical decisions does not come from classical double-blinded randomized studies. That does not make it any less evidence-based than medical oncology, where a great deal of the evidence comes from randomized, double blind, clinical trials, simply because it's much easier to do such trials when what is being compared are two different drugs, rather than two different operations.
While I definitely understand that it is infinitely more difficult to conduct RCTs (particularly patient blinded) in surgery trials as compared to drug trials, I do think that this difficulty makes surgical fields somewhat less evidence-based. It seems as though the difficulty in conducting high quality studies too often prevents them from ever being done in a timely manner, in which case the new procedure becomes accepted as the standard of care and then comparisons are more difficult to "ethically" conduct. I think that the surgical fields need to start pushing much harder for the bar to be raised in what is considered a high quality surgery trial. Far to many treatments seem to only have case series type evidence or trials that include only a handful of patients with limited evidence of randomization or no blinding of the people who assess outcomes. Until the standards are improved, it would seem that many surgical treatments will remain less evidence-based than they would have to be. This of course is just my opinion and no fault of yours.
Sorry, for even including this minor off-topic quibble, since I thought your response was excellent and I definitely will be looking forward to reading more from you in the future. Thank you.
deconstruction (isn't decon the french intellectual's sly joke, perhaps revenge for jerry lewis) is funny enough when applied to literature -- therapist becomes the/rapist -- and becomes a real howler when applied to medicine.
"Is it just me, or does "microfascist" make anybody else think of a midget Hitler?"
There you go again, bringing it back to the pymies and the dwarfs!
Is it just me, or does "microfascist" make anybody else think of a midget Hitler? Like Mini-Me with a moustache! Although, come to think of of, Mini-Me already looks a bit like midget Mussolini... Hm.
Actually, I had thought of that. I should have asked whether being a "microfascist" mean that I could only wear really tiny jackboots and wield a really tiny truncheon?
...teeny-tiny hobnails on the tiny jackboots...
For Stephen Gould's account of how he used evidence-based medicine to deal with his mesothelioma, see here:
The most insidious part of this article is its arrogant assumption that evidence is bad for you.
What really bugged me is that if it is an appeal for respect for different ways of knowing, why didn't they mention a single other different way of knowing?
Because they don't know any, or even to them they sound stupid.
"The most insidious part of this article is its arrogant assumption that evidence is bad for you. "
Slightly off topic, but does this mean that fair courtroom trials with sworn testimony, vetted evidence, and impartial juries are now considered fascist by the PoMo set?
Orac, you are my hero.
Did my PhD work on Deleuze in the early 90s and read a lot of this sort of misappropriation of Deleuze's philosophy. A quick glance at their references told me all I needed to know. Any discussion of medicine and postmodernism that does not include reference to G. Canguilhem's "The Normal and the Pathological" is problematic, to say the least (of course this text would have undermined most of their "position", so perhaps it was an intentional omission . . .). The texts they used from Deleuze, Foucault, Derrida and Lyotard are the most simplistic of these authors' works and reveal not only a lack of understanding about medicine, but also a lack of understanding about postmodern philosophy. I refer to these as "Theory Applique" (in concert with a certain suburban fashion of gluing sequins, cloth and texts to polyester jogging suits to be modelled at the local shopping mall . . .).
What really bugged me is that if it is an appeal for respect for different ways of knowing, why didn't they mention a single other different way of knowing?
Especially when there are so many promising possibilities. Let's see...
1. Coinflip-based medicine: 'Heads! I have bad news. You've got (flips three more coins) four weeks to live!'
2. Ouija-based medicine: 'Oh! It's moving! It's moving... H... E... R... P... E... Ummm. Okay. We're done. I think I can see where this is going.'
3. Prime-time sci-fi technobabble-based medicine: 'Well... we could try reconfiguring the patient's primary phase array... but that might take weeks!' 'Make it so! You have an hour!'
4. Astrology-based medicine: 'Mercury is in transit... heavy metal poisoning.'
5. Nostradamus-based medicine: 'Let's see... De sang barbare sera couvert de terre... Damn. You'd better sit down... Comfortable? Good. I'm afraid you have leukemia.'
6. Jungian dream interpretation: 'Yes, I know I haven't interviewed you yet. But I saw an enormous tower in my dreams, last night. So I'm betting on blue balls.'
7. Numerology-based medicine: 'Well, when you came in here, the clock read 1:50. And the last three digits of your chart ID are 100. High blood pressure. But not to worry. Just have reception schedule you for a 1:20 later this week... I'll try to be on time.'
8. Dartboard-based medicine: 'You have...' thunk... 'erm... is that on the triple 20? Damn. Looks like Black Death. First time this morning!'
By far the most annoying thing about the article wasn't that it was full of pretentious gibberish and unnecessary name-dropping, or that it was a cookie-cutter replication of the standard arguments about mutually reenforcing power structures and epistemological frameworks, or that the author exhibits an almost delusional level of political paranoia (as annoying as all those were), but that it never actually got around to actually deconstructing the EBM paradigm.
Only a couple sentences actually talk about the epistemological details of the EBM paradigm and how they shape the discourse, and never with any significant detail or serious reflection. There are actually significant areas to be explored here (for example: "Best Practices" create modalities in diagnosis and treatment that clinicians are often compelled to follow by the institution they work for - how does this influence the structure of the dialog between the clinician and the patient and how the clinician interprets what the patient says? What kinds of research and researchers are excluded by the preference for RCTs and what effect does this have on the direction of research in the health sciences?).
The authors also don't seem to grasp that science isn't and shouldn't be epistemologically neutral. Science requires a community with a shared paradigm to function(sufficiently different paradigms are "incommensurable"). If the epistemological assumptions of two paradigms are different, they cannot contribute to a single body of knowledge, since they don't have the same definintion of what constitutes knowledge. A consistent definition of what constitutes scientific knowledge is a feature, not a bug.
rcook wrote, 'The texts they used from Deleuze, Foucault, Derrida and Lyotard are the most simplistic of these authors' works and reveal not only a lack of understanding about medicine, but also a lack of understanding about postmodern philosophy.'
After being exposed to some rather startling po-mo arguments, I thought the founders of the philosophy must have been cranks. The idea that reality is only a consensus of our opinions? Huh? Like Dr. Johnson, I'll just kick the stone.
Then I got to the point of reading a bit of Foucault (many years ago now) and I was surprised at how much some po-mo enthusiasts got from such vague source material. The basic premise of po-mo seems to be that our perceptions of reality are more mallable than we give them credit. I can accept this view. Yet, some of the enthusiasts have taken this to mean that reality itself is mallable.
One of these days I'll have go back and read Deleuze and Derrida and see if their writings have anything to do with the reality denying po-mo nutters.
Since you seemed to have studied Deleuze greatly, do you, rcook, have any insight as to whether Deleuze would have agreed with the authors of this paper?
Thanks in advance,
How many tiny jackboots can stomp on one human face forever?
Seriously, though, I have a hard time believing that anyone thinks giving lies equal standing with truth is "diversity". Or is a positive trait no matter *what* you call it.
Of course, we do not wish to deny the material and objective existence of the world, but would suggest, rather, that our relation to the world and to others is always mediated, never direct or wholly transparent.
One of PZ's commenters pointed out that the mediator between us and the world cannot itself be real, or we would need another mediator between us and it, leading to an infinite regress of mediators.
Does that mean that our relation to the world must be "mediated" by *unreal* entities that are *not* part of the world? Ghosts? Angels? Demons?
It seems to me that postmodernism takes the entirely reasonable starting point that we can never be 100% sure that our *perceptions* of reality are *accurate* (although they are mostly accurate most of the time), and jumps off into the absurd belief that therefore there isn't anything to perceive and we're all just making up the universe. Then they try to deny that, while still keeping their entire philosophy based on it.
This makes no more sense than solipsism.
Brent: Remember that RCTs may be the "gold standard" as far as testing, but they aren't the only way to gather evidence. There are fairly standard ways to collect and refine data from a large supply of less-controlled observations, such as clinical observations and large numbers of case studies. This ends up being much slower to achieve reliable results, but it gets there eventually. Of course, some surgical questions can be tested on animal models, and then you can do RCTs on the animals!
"You know, the other night I dreamt that a fairy told me how to cure autosomal
dominant medullary cystic kidney disease but no fascist EBM journal wants to publish my findings! My completely valid, non-evidence based knowledge is being ignored! It's not fair!"
"Mediation" in this context appears to refer to the process via which sensory inputs are interpreted into ideas. It isn't the same as solipsism because it doesn't doubt that sensory inputs correspond to something "real", but instead raises doubts that because the framework in which they're interpreted isn't transparent to us, we cannot know whether or not our way of interpreting is correct.
Ruth: you almost beat me to it. Before I saw your response, I had a hunch that the entire article could be summarized in five words: The World Doesn't Appreciate Me, i.e. the universal adolescent lament. After reading your response, I decided that my hunch was more of a certainty.
Seriously, I think the major motivation for a lot of woo is people's wishes to live in a world that appreciates them. Where they really jump the track is wanting the physical world at a physical level to appreciate them, when appreciation is something only people can do (people are, of course, physical beings, but we're the only part of the physical world that can give rise to emergent phenomena like appreciation).
The short answer:
I think Deleuze would have disagreed with the authors on a number of levels.
The longer answer:
Without getting into too much po-mo jargon, first of all "deconstruction" is not something you "do" to something as their title suggests-- it is a quality that exists in a thing, such as language or science or medicine that undermines the idea of stability, especially unchanging Truth. What they are doing is critque. Furthermore, if Orac is representing EBM acurately, it seems to hardly be a monolithic, stable force of Truth. In fact, it seems to recognize and demand constant change, thus embodies the concept of deconstruction as Derrida conceptualized. Now there is also the issue that "deconstruction" is a term Derrida popularized (which he got from Heidegger) and Deleuze never used the term (those French boys liked to keep their sandboxes segregated and quality schalorship would respectfully do the same). The authors do mention a Deleuze term in their Objective:
"The philosophical work of D+G proves to be useful in showing how health sciences are colonised (terrritorialized) by an all-encompassing scientific research paradigm -- that of post-positivism -- but also . . ." Deleuze however, insisted that such "territorializations" were necessary, as long as they later became de-territorialized (thus avoiding the fascism [at micro or macro levels] the authors mention).
I think Deleuze would have found the constant flux and change apparent in EBM as an embodiment of exactly the sort of re and de territorializations necessary to avoid fascism, and hardly the "micro-fascism" of post-positivism the authors refer to (to my knowledge this is their term, not Deleuze's-- although Deleuze did use the term micro-politics AND since they did not define what they mean by post-positivism, I have no idea what that means to them).
Again, I think Orac is correct-- they misrepresent EBM as monolithic in nature, in order to create a straw man argument.
I've often said that the value of postmodernism is the insight that how we think is often as important as what we think. Beyond that, though, it gets wierd.
The journal in question is a Blackwell publication (so it's probably profitable), and this issue seems to be centered on the "evidence based" problem. In other words, it's entirely possible that this was one of those "conversation starter bombs": a radical position which, when attacked by realists will reveal itself as "just a conversation starter, not something we're committed to" so they can make their point and then back away...
Just from titles alone, and not being in medicine myself, the most cited articles look reasonable, and the journal itself is a Joanna Briggs Institute project. Their self-description actually looks very similar -- perhaps a bit broader -- to the Cochrane Reviews material you cited.
I think that you misread what I wrote, or I wasn't clear. I am an epidemiologist who spends that vast majority of my time conducting research that doesn't involve RCTs, and I agree that in many instances the non-RCTs can be more appropriate than an RCT (i.e. Look at smokers and non-smokers, control for known confounders, and decide who gets lung cancer the most. This avoids randomizing people to smoking and waiting 30 years.) My point was that often times it is possible to conduct either a randomized or another type of "more controlled and less biased" type of study, but instead case-series are reported because they are much easier and cheaper.
Therefore, I am simply saying that the system often times rewards researchers for publishing ANY type of study, so there is a decreased incentive to conduct a very difficult and expensive, but well-done study when a cheap and sloppy study will also get published. The problem is that in evidence-based medicine it is garbage in gabage out, so "cheap, but sloppy" studies are actually very expensive because they yield little valid evidence per dollar. I would say that if the bar is raised on the acceptable quality of a study accepted for publication, then the amount of evidence per dollar spent will be increased. It just so happens that it is more expensive to conduct high quality evidence-based medicine in surgical fields than it is in some other fields. It doesn't make surgery or surgeons bad, it just means in order for surgery to become as "evidence-based" as some other fields, they will have to spend a lot more research money. Currently, I don't think that surgerical fields have as fully adopted the evidence-based type of approach because of these difficulties. This isn't meant to be a knock on surgeons, but a statement that the benefits of EBM are worth some additional up front costs.
My spelling and grammar are terrible.
I didn't mean to draw the discussion off topic. I thought Orac's post was great. I generally favor increasing EB,M and I think that all fields could be helped by improving the way we gather and use evidence. I don't mean to pick on clinicians who cut patients more than clinicians who drug or otherwise treat patients.
I see that po-mo still hasn't progressed much past Pyrrho.
Who needs EBM when David Copperfield has found the "Fountain Of Youth"?
What's the over-under on alties going nuts about this?
This is the kind of thing that simply amazes me, and leaves me stunned.
When I was diagnosed with cancer, believe me, I wanted my surgeon to use medicine based in reality, as shown by evidence.
Who would want their doctor to make it up as he went along - not relying on evidence that his treatment would work?
I cannot wrap my mind around this.
My bio textbooks are obsolete within a year or two, and they're citing a bunch of theorists from the '50s and '70s.
Who's supposed to be ossified and entrenched in their thinking here?
excuse me, but am I mistaken? I thought that the article was satire, like something from the Journal of Irreproducible Results. I think you all got taken. No way is that pseudophilosophical bullshit for serious.
The article did answer a pressing question for me, though: I'd always wondered where Dr. Nick of The Simpsons went to medical school, and now I think I can narrow it down to either the University of Ottawa or Ryerson University in Toronto. That's a useful thing to know.
Or maybe the University of Alberta---- not only is our pediatiric hospital bringing in the alternative practitoners, to gather evidence of course, but the Hope Foundation of Alberta based out of our illustrious university, is geared towards "studying hope". ---- Yep- our tax dollars are at work trying to make medical costs negligible with the addition of hope and prayer....
I thought that the article was satire
tdoc: As I cited above, this seems to be legit. And if you go looking at some of the anti-pomo writings of folks like Ophelia Benson, you'll find that there's lots of this stuff around. We're hoping it's a phase....
Great post, you certainly hit the nail on the....
eep eep eep brain fart!
They've convinced me, in spite of your "knowledge" Orac, I will henceforth dedicate my life to demanding that NASA include alternate gravitational realities in all programs. This sticking to the old fashioned, repressive gravitation must end. Let a thousand tensors blossom.
Just don't ask me to get in the capsule, or under Deleuze's blade.
Am I the only one beguiled by bad eyes and tiny fonts into reading "pomo" as "porno"?
It makes you really wonder. How to convince someone of the values of evidence if they do not believe in evidence?
Sorry, I missed the citation. Well...it sounds like it was written by the National Lampoon and it makes about as much sense. By invoking the principles of deconstructuralism,and despite what the author intended, I say it is lampoon and satire. Maybe the author was just too dense to realize it. So there!
tdoc: easy mistake to make. There's a powerful and unacknowledged circularity to deconstruction, and a hypocrisy as well (neither means that it's bad, just that it's neither as rigorous a method nor as consistent an ideology as its adherents believe), and that's in good deconstruction. In bad deconstruction, into which category most attempts to apply the theory to science fall, it's just woo.
I think that they are upset that science and reason are usurping faith and hope. In a sense, science deconstructs religion. So it seems they are trying to do the same to science by saying that science ignores the "soft stuff" that makes us human and not beast. Yes-No???
This is what the whole "holistic" movement seems like to me- a bunch of people who decry scientific medicine as reductionist and then try to heal the WHOLE person- body mind spirit emotions yada yada yada ad infinitum. Freaking annoying as hell. These seem like the type of people who see illness as an effing journey of self discovery, rather than an inconvenience and a horror.
By the way, I like Foucault, and have read him over the years. He is a Social Sciences darling. He does talk about how the medical elite have power over information they give to patients- but he was writing years before the internets were founded. Now we have at least an idea of what medical options are available for specific diseases, all in a moment or two.
My post modern view on this is that there will still be a third of docs who hold info close, a third that are mediocre and a third who are excellent at what information they can provide to a patient. I think that it will cost more for specialized (read real) medical treatment, and more whackos will come out of the closet to fill the void, as nature - even post modern nature- abhors a vacuum. We are seeing an increased interest in the power of prayer, excorcism and other faith based nonsense.
So- is having more information available as a patient a good thing or a bad thing- both for patients and for docs??? Are most people capable of making reasoned judgements in regards to reatment options, or is it a case of ease of treqtment (palatability) or even the most persistant practitioner "winning" ???
I only had to read the abstract to say "this is why I left the humanities."
Perhaps this, like the infamous Social Text paper, will turn out to be a joke.
Over at Bad Science http://www.badscience.net
Dr Ben Goldacre (it's his site) does a fine demolition of
this tripe. He also points out:
August 18, 2006 at 2:50 pm
archie cochrane didnt just fight for the international brigade, he dropped out of medical school to go and fight for them. what a hero. and then he was a prisoner of the nazis for 4 years.
cochrane fought real fascism and totalitarian violence, and he was cool with it: in his autobiography he explains that he was only caught by the germans in the mediterranean because he couldnt swim to egypt. what a geezer!
Thank you for dispelling this dreck. Very funny.
i thought fascists preferred to oppress entire countries and shoot all citizens who fled? i was not aware they had moved into keeping down just certain areas of research...mussolini would be shocked at the lack of imagination.
as an english major and medical librarian i think this is the funniest bit i've seen on ebm - almost as good as the piece about trout fishing.
Thanks for an interesting reading what draw out such comments above
I'm late weighing in here. Just a couple of points.
1) Although these guys paint a distorted picture of what EBM really is there are EBM extremists (people who tell us what we can and cannot read, or declare that we should never listen to experts) who fit the description.
2) We have to be careful using Medline as the test for legitimacy. As fellow warrior against pseudoscience Wallace Sampson has pointed out, Medline indexes many quack promoting journals while excluding his appropriately critical Scientific Review of Alternative Medicine.
You're familiar with the basic categories of alternative ways of knowing:
-Fetishization of "exotic" cultures (see tradition)
-Argument from analogy
and the all time champion,
-Making shit up!
If EBM is microfascism, is homeopathy picafascism?