EBM: unmasking the ugly truth
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7378.1496 (Published 21 December 2002) Cite this as: BMJ 2002;325:1496All rapid responses
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Dear Sirs,
Is the move complete from the early idealistic vision of an Evidence-
Based Medicine (EBM) to the earthly establishment of an Evidence-Biased
Medicine, complete with priests, liturgy and Holy Inquisition? I think
not, at least not yet. But the Clinicians for the Restoration of
Autonomous Practice (CRAP)'s fortuitous uncovering of the EBM religious
tracts in the making (1) sounds a none too early alarm. Practitioners who
idealistically continue to apply available evidence to medicine will
increasingly have to fear the wrath of the zealots when they resort to
that most lay of clinical approaches: common sense.
Prompted by your revelations, I discovered more of EBM's dire consequences
by opening the website of a Regulatory Agency and then playing the CD of
an approved EBM textbook in html:
1. Only corporations that can afford to punt one billion dollars per shot
and then wait around 10-12 years to reap the benefits, if any, are allowed
to develop new treatments.
2. New potential indications of older drugs are not worth exploring. A new
patent will only last 3 years and nobody will invest for everybody else to
grab the benefits.
3. Ditto for "traditional medicine". We all sneer at it, idealists and
zealots alike, precisely because of the lack of evidence but the costs of
an EBM approach to prove the worth, if any, of a specific remedy will
never be met.
On top of failing to provide evidence that it does more good than harm,
EBM may actually be stifling medical progress, in cahoots with regulators
(and class-action suitors). That the number of new treatments available to
patients has considerably declined in recent years may be due to a
cyclical pattern but could also result from the huge deterrent that
current regulations impose on proponents. Whether EBM will implode, as
CRAP suggest, only time can tell. If that time is nearing, though, will
Sampson take down the temple with all the philistines?
1. Clinicians for the Restoration of Autonomous Practice (CRAP)
Writing Group. EBM: unmasking the ugly truth. BMJ 2002;325:1496-8.
Competing interests:
None declared
Competing interests: No competing interests
Thanks to the good folks at CRAP for the smile!
As I spend a good deal of time teaching EBM, I am constantly
reminding colleagues and students that EBM is a union of the best
available evidence, clinical expertise, and patient values and
expectations. One just doesn't work without the other two.
In many cases, the best available evidence is found in sources other
than double-blinded RCTs. That doesn't preclude the need for the clinician
to maintain an awareness of the best available evidence in his/her
specialty. There's a difference between autonomy and selective ignorance.
And ultimately, the patient gets to choose what treatment they will
accept, a fact forgotten by many factions in our profession.
Happy New Year to all.
Competing interests:
None declared
Competing interests: No competing interests
While it is amusing to debate the merits of evidenced based medicine,
there is a bit of evidence missing in medical practice, at least in the
U.S., and it causes hundreds of thousands of deaths a year from medication
errors.
The missing evidence is what medication the patient is on and lack of
immediate access to laboratory and other reports at time of prescribing.
Inpatient problems have been well documented in the literature.
Outpatient problems are not, even though initial estimates of outpatient
mortality due to medical error are substantially larger than inpatient
mortality.
For example, a leading concern of health maintenace organization MDs
and executives in Massachusetts is that only the pharmacy and the health
maintenance organization have a reasonably complete list of patient
medication history and the patient's own statements about their current
medications are notoriously unreliable.
As a result, in the outpatient setting in Massachusetts, physicians
are prescribing in a virtually zero based evidence setting, since they do
not normally call the pharmacy or check with the health maintenance
organization before prescribing.
Given this situation, the concerns about world dominance of EBM are
vastly overrated.
Competing interests:
Mobile computing professional
Competing interests: No competing interests
Dear Sirs and Madams,
I am writing this as a simple, EBM-challenged, orthopaedic surgeon (is this re-iteratively redundant?). At any rate, I have a question that may get to the heart of the problem that CRAP has so eloquently uncovered.
In the course of practice in orthopaedic surgery (although not documented in the literature), it has been my experience (those of you who adhere to the EBM doctines hopefully will excuse this phraseology) that when I hit my finger with a hammer (or mallet, for that matter), my finger hurts. It is even worse if I use a power tool (like drilling through the finger). My question: how many times do I have to do this before I can say that I have sufficient evidence to potentially causally link the hammer blow to my finger hurting? And what do I use as the control?
One of my teachers in medical school once noted that fields such as Orthopaedic Surgery were very difficult for some physicians to master because they required the exercise of "common sense". Is the inability to use "common sense" (CS) what lies behind the development of EBM? Perhaps it is an attempt by the CS-challenged among us to make the CS-gifted feel bad (or just inadequate). I think this is an area of research that CRAP might find fruitful as they continue their investigations into this new religion.
Competing interests:
I like hammers and power tools
Competing interests: No competing interests
I read this article with fun!
In Japan, some EBMers including me think EBM as
social movement or ideology and so on.
The "level of evidence","Grade of recommendation"
something like that used in EBM are merely expert
consensus of EBMers. EBM itself is neither impregnable justice nor
diviness.
Every medical evidence is made or interpreted by humans.
Evidences are socially constructed.
God bless you all
SAIO
Competing interests:
None declared
Competing interests: No competing interests
what about the rumour that the falung gong are EBM / NON-EBMers &
that is why they are being persecuted in china etc.?
is there any evidence that exchanging messages of goodwill in the festive
season actually works double blind trials seem unlikely can meta-analysis
help?
pro temporore with belated best wishes & all the relevant compliments
of the festive season to all bmj readers including those dear to each
& every bmj reader/s.
g'day to youse all from oz srk.
Competing interests:
solo GP
Competing interests: No competing interests
How and where can I join or subscribe to CRAP?
Perhaps I was mistaken, but when EBM first was translated to the U.S., it
seemed like the translation of the Bible into English. It was the taking
the research community and putting the results into the hands of the
common physician. We might not have the time with every patient, but with
training any physician could look at the evidence and understand how we
came to a conclusion or a treatment, or understand that there was no hard
evidence, just clinical practice. It was populism. It was wonderful, and
those who came to understand it felt like missionaries spreading the word
to all. You can do it too.
However, now it has become a dogma. Unless the Cochrane or the AHCRP
have made a recommendation or review, the conclusion or research or
practice is not "Evidenced-based." Books are called "well-researched" but
they are not "evidenced -based" unless they spout the conclusions of a
very small number of organizations whose members we only vaguely glimpse.
And the number of organizations
is shrinking. Soon we will have to practice medicine on the basis of a few
precepts. So how can I join CRAP? Or is it going underground like the
Christian into the Roman crypts? Jo Ann Rosenfeld MD
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
I have just been sitting down to a Christmas drink with my wife who
has just bought a wonderful local book on Italian cooking. She extolled
the virtues of the book which contained all sorts of handy hints on how to
adapt the preparation of these dishes for our subtropical climate where
food goes sticky or does not set unless put in the refrigerator. Such
culinary information has been handed on from generation to generation;
from mother to daughter and from father to son.
“Harrumph! I thought. “But where is the evidence? My wife looked up
from the book momentarily as if I was raving fruit-cake and kept reading.
“….. physicians,” she thought. “We psychiatrists have been good cooks for
years”.
Evidence-basted cooking must be introduced lest we fall into the trap
of observer bias,anecdotes de la cuisine and other unmentionable heresies.
I have just finished a revision of an article accepted for
publication on a large number of patients followed prospectively because
they had neurosarcoidosis. How I longed to add a few handy hints; some tit
-bits of useful experienced-derived recommendations…..even an occasional
“caveat emptor”. Alas, I dared not use the first person pleural, let alone
singular, the active rather than the passive voice and heaven forbid,
opinions devoid of p values or correlation co-efficients.
How about a medical version of the Larousse Gastronomique with a
special rubriques such as “Irrefutable sauces basted with lashings of
expensive évidence and topped off with the finest VSOP Almanacs from
Gascony”?
Countless hours of experience, the “hard yards” of innumerable
physician-cooks and the wisdom only years in the kitchen can bring, are
being squandered to that deity, Évidences-de-Bases-Médicine (EBM).
Give me the Italian restaurant where the cooking is done by a woman
from the slopes of Etna. She can take out my appendix too.
Happy Evidence-baste Christmas from sunny Brisbane,
Roger Allen
Competing interests:
None declared
Competing interests: No competing interests
I also performed a Google search on Dec 22 using "EBM" and got
292,000 citations. Howcum the CRAP team got 1,240,000? We need more
evidence to see who is right!
Cheers and Happy Holidays to everyone!
Competing interests:
Absolutely! See my other missives.
Competing interests: No competing interests
Should competing interests have been made explicit?
I admired this article, which I assumed was a spirited, and brave,
satire on the disciples of evidence based medicine. When I followed the
trail, and discovered that the authors were none other than Andy Oxman and
Iain Chalmers, two of its more prominent exponents, I admired it even more
(particularly the barbed last sentence) as an excellent piece of
propaganda.
But was it ethical? Should not the provenance of this piece have been made
explicit? After all, as some of the rapid reponses have shown, some
readers seem to have been misled.
Or do such standards apply only to data, not ideas?
Competing interests:
I might have been able to have written a more biting satire
Competing interests: No competing interests