Fighting Against Evidence

http://www.sciencebasedmedicine.org/fighting-against-evidence/

by tokenadult • 12 years ago

45 55 12 years ago

thrush• 12 years ago

It would be nice if we had some sort of independent research verification system. Basically a group or individual that validates the most important (or highest paying) publications.

nocoment• 12 years ago

I still don't understand why a consortium of insurance companies doesn't run studies looking for better outcomes with out-of-patent and un-patented drugs.

Their tests would be of already approved drugs.

In many situations they could save a bundle and in others they would dissuade drug companies from pushing the advertising and costs.

The statistics on everything they test would show their general level of bias (assuming drugs aren't getting any worse.)

Mz• 12 years ago

Um, no offense, but do you have any idea what insurance companies are really all about? That sounds, well, crazy to me (as someone with a) a serious medical condition and b) who used to work for an insurance company).

glomph2• 12 years ago

Because if treatment gets cheaper they have less business?

ensignavenger• 12 years ago

Many insurance companies (I think that now perhaps all of them in the US, thanks to ObamaCare) have to pay out a certain percent of what they take in to health providers. Thus if they want to increase premiums, and therefore profits, the only way to do it is to increase the cost of care. Preferably, they increase the cost of care for everyone, which drives more people to buy insurance, and means that some other company isn't able to undercut them on premiums by reducing costs. Of course, they als get more float, which insurance companies love. That is the model that health care insurance companies follow, and ObamaCare was a huge gift to helping them out.

shimms• 12 years ago

We do - cochrane reviews (http://www.cochrane.org).

From their about us page:

"Cochrane is a global independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about health. We are a not-for-profit organisation with collaborators from over 120 countries working together to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest."

benched3• 12 years ago

Terry, why do you regularly use racially charged language? I understand your meaning fine, I'm just curious whether there's any specific reason you use racial language so much, or if it's just sort of one of your things.

tokenadult• 12 years ago

Did you put this comment in the wrong thread? There is no one named Terry here (the author of the submitted article is Steven Novella). It doesn't look like you read the article that was submitted to open this thread before you typed your comment here.

anonymoushn• 12 years ago

benched is replying to TempleOSV2, who is hellbanned.

Crito6• 12 years ago

I don't think that he is well; I wouldn't read to much into it.

benched3• 12 years ago

I understand that he has schizophrenia, but they're people with thoughts and reasoning, too, though they may be more loosely aligned with the consensus style of cognition. For example, the statement he made makes perfect sense semantically - it's just said in a way that a lot of people find offensive.

BlackDeath3• 12 years ago

I understand your meaning fine

You do?

Crito6• 12 years ago

I thought the overall meaning was clear, no matter how poorly stated: "Doctors do not do calculus" -> "medicine is not a hard science" "People who are not in hard sciences should not be trusted"

Then he has the output of a markov chain or whatever that he seeded with biblical texts. You can safely ignore those sections.

Basically (racist language aside), his comment boils down to "Anyone who isn't STEM sucks." It would be an extremely low-quality comment even if it were articulated well.

jostmey2• 12 years ago

I am torn. On the one hand I firmly believe that medicine should be evidence based. Treatments should be based on the best possible scientific evidence. Inevitably, such evidence will rely on large, randomized controlled clinical trials...

On the other hand, I take it as my own personal responsibility to take care of my own health. This means that I have to rely on a sample size of one. If I try something, and I feel better then I try more of it. My prescription for myself may not work for anyone else, it could be specific to me.

I personally believe that Western medicine is awesome because it is evidence based. At the same time, Western medicine has removed from the individual a sense of personal responsibility, and this must change.

icebraining• 12 years ago

Well, Eric Topol[1] argues that evidence-based medicine, coupled with copious amounts of data and better tools, will allow treatments to be much more individualized, not less.

[1] http://www.scripps.edu/research/faculty/topol

http://www.econtalk.org/archives/2013/04/topol_on_the_cr.htm...

http://www.amazon.com/Creative-Destruction-Medicine-Digital-...

Crito6• 12 years ago

IMHO, the problem with "alternative medicine" is less what adults do (or do not do) to themselves, and more with what adults do to children that they have been entrusted with.

Thankfully there has been progress in recent years on this front, with adults who neglected to seek evidence-based medicine for the children that they were entrusted with being charged with homicide (http://en.wikipedia.org/wiki/Kara_Neumann_case). There is more progress to be made however.

npsimons• 12 years ago

Western medicine has removed from the individual a sense of personal responsibility, and this must change.

I must heartily disagree. Well, perhaps not so much disagree as clarify: Western medicine as it is practiced, perhaps discourages personal responsibility (and how many times would you tell patients to eat better and exercise more if they never did?). Evidence based medicine is just that: based on evidence. There's no "removal" of personal responsibility, there are simply facts, as in your case you have brilliantly demonstrated: when something works for you, you continue to use it. My immediate reaction to "trying something" that you mentioned, however was "how many things did you try?" How many people won't research different options, much less put them into practice, simply because it would require them to try something different, or something hard (like exercise)? How many people would rather take some snake-oil to lose weight than eat less and exercise more? How many people will refuse vaccines because they believe it's a government conspiracy?

And let's not forget all the other confounding factors, such as big pharma with 85+% of their money dedicated to marketing, or the placebo affect, etc, etc.

jostmey2• 12 years ago

Western medicine has removed from the individual a sense of personal responsibility in the following sense. We are told to ignore what may work for us and to instead try what works a large number of other patients. While the advice may be good advice, it leaves the patient with an attitude that their own ideas about how to treat themselves may be worthless. And this could encourage the patient to place their doctor upon a pedestal - only the doctor knows what is best for you.

Of course, some advice is just always good advice - eat right and exercise. But you don't need a doctor to tell you that. I have observed that it is the same people who take the best personal care of themselves, by eating right and exercising, also engage in alternative medicine. The very act of trying to take control of your own health leads you to focus in on what works (or what you "think" works) for you.

mchusma• 12 years ago

First, the concept of "Western Medicine" is a misleading one. It implies there it is the opposite of "Eastern Medicine". Evidence Based Medicine, the subject of this post, is a much better term. Any methodology is appropriate, so long is it is backed by science.

I think Evidence Based Medicine puts personal responsibility on the individual. Individuals need to realize that Marketing does not Equal better care, all that matters is the science.

Evidence Based Medicine has nothing to do with personalized medicine, it is simply a way of analyzing the efficacy of medicine...science.

Crito6• 12 years ago

The "Eastern"/"Western" dichotomy also ignores the existence of many scientifically questionable/discredited practices that originated "in the West". Homeopathy and chiropractic are both examples of prominent "alternative medicine" from 'the West'.

Similarly, plenty of medical techniques developed in 'the East' are backed by evidence.

Alex39174• 12 years ago

Western medicine or, more accurately, allopathic medicine, is actually a much better term than Evidence Based Medicine because most of medicine is not especially evidence based. There are countless studies and books on this topic.

dllthomas4• 12 years ago

"If I try something, and I feel better then I try more of it."

Conclusion: laudanum for everything!

fnordfnordfnord• 12 years ago

My favorite semi-facetious/sarcastic journal article: http://www.bmj.com/content/327/7429/1459

"Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute."

And a less facetious one http://www.bmj.com/content/333/7570/701

Both of which point out obvious shortcomings of slavish reliance on large, randomized controlled clinical trials for every circumstance.

gress• 12 years ago

The problem is not with the concepts of SBM and EBM but with the fact that they are not understood and applied well by doctors, and often just translate into not being able to think beyond 'results' handed down from the establishment.

aaronem2• 12 years ago

"Do you know what they call 'alternative medicine' that's been proved to work? Medicine."

(from http://www.altairiv.net/Storm.html)

glomph2• 12 years ago

This quip really annoys me. It only seems true because of a confusion or blurring of two very distinct concepts. There is tested treatment, which has been tested and come out effective. This can be put in dichotomy with untested or failed treatment. That is logical. Some treatments have been tested and passed some haven't. This is an entirely different dichotomy to that of mainstream and alternative or complementary medicine. Many forms of medicine have been thoroughly tested and come out effective and are not offered by pharmacies and national health services. Unless you want to claim that absolutely all proven effective treatment is offered by mainstream medical providers then this has to be acknowledged. Then on the other side there is a large array of medicine that is provided by mainstream medical providers that has not been proven effective. Many antidepressants consistently score the same or worse than a placebo in blind tests.

The distinction between alternative medicine and mainstream medicine is not proof, but the provider. So while Minchin may be eloquent he is confusing terms to make his point.

reverius42• 12 years ago

The difference is not in the provider, but in what is being provided. Alternative providers provide alternative medicine. What you call "mainstream" providers provide tested, evidence-based medicine.

Certainly there are some who provide both, but they should probably know better.

dllthomas4• 12 years ago

Eh, I think the quip is entirely an appropriate expression of how things should work. It is also not horrifically inaccurate as a description of how things do work, 1) as far as it goes, and 2) in the medium to long term. Both of these caveats are important. It does not say that all mainstream medicine is proved - we should hopefully be moving in that direction, particularly with the EBM push, but while granting there is a lot of baggage the comment does not say "everything we call medicine is alternative medicine since proved", it says "when we prove alternative medicine, it just becomes medicine" - which it does, eventually, as demonstrably effective treatments are adopted by mainstream practitioners - which, over time, they do tend to be.

Alex39174• 12 years ago

The problems with this are that:

1) You're implying that the vast majority of effective treatments are alternative medicine, and saying that 100% of effective treatments were at one point alternative medicine.

2) Most of what you refer to as medicine has not, in fact, been proven to work. In the U.S. (and all other countries) there is no legal requirement to prove that a drug is safe or effective before selling it, you only need to provide weak evidence that the drug is plausibly safe and effective. Oh, and you're also allowed to purposely bias the trials as much in order to produce this modicum of required evidence.

I think it's funny that the people who believe the most in medicine (and science in general) are the ones who don't read many books. Although to be fair that's exactly the same as with every other field. But still, I feel like statements like the above basically just glorify our culture of ignorance.

tensor2• 12 years ago

I think it's funny that the people who believe the most in medicine (and science in general) are the ones who don't read many books.

This is an odd statement. It's certainly true that as people learn more about a subject, they tend to realize how much they don't know and become more humble. But that doesn't mean that they start preferring non-science methods, which it seems like you are implying.

Diederich• 12 years ago

The implication in this quip is that anything that is proven to have positive medical value will end up being accepted into the mainstream.

Counter-example: http://en.wikipedia.org/wiki/Medical_cannabis

How many decades has it taken?

aaronem2• 12 years ago

Eight, more or less, and at the start of that period, scientific medicine was barely out of infancy. I don't believe anyone has suggested that either perfect wisdom, or immunity to political considerations, are among the traits of that field of science.

gone35• 12 years ago

Evidence-based medicine.

As opposed to what, speculation-based medicine? Call me old-fashioned, but shouldn't all modern medicine be 'evidence-based' by definition??

Crito6• 12 years ago

As opposed to what, speculation-based medicine?

Well, yes. The idea is that "speculation-based medicine" (better known as "alternative medicine") is, despite the name, not actually medicine.

Hence the Tim Minchin joke: "You know what they call alternative medicine that's been proved to work? ...Medicine."

dllthomas4• 12 years ago

I wasn't under the impression that alternative medicine was the only thing that was not "evidenced based" - that while clearly it's an extreme example, there is plenty of traditional medicine that doesn't make the cut. Wikipedia seems, at a skim, to concur: http://en.wikipedia.org/wiki/Evidence-based_medicine

fishtoaster• 12 years ago

You'd think so, wouldn't you? However: http://en.wikipedia.org/wiki/Alternative_medicine

mturmon2• 12 years ago

I don't know, there are plenty of cases where the stuff we thought qualified as "evidence", and definitely turned into medical practice, turned out to be wrong.

Examples: stress causing ulcers, cough medicine for children, diet (carbs good or bad? cholesterol horrible or inconsequential?), prostate cancer screening, certain kinds of corrective surgeries.

erkkie2• 12 years ago

and like many orthopedic surgeries have turned out to be not better than noninvasive alternatives ( my personal pet peeve is the knee: http://www.nejm.org/doi/full/10.1056/NEJMoa1301408 , http://www.nejm.org/doi/full/10.1056/NEJMoa0708333 ).

In general surgical procedures are much more based on anecdotes and personal experiences (of the surgeons) than long term evidence of efficiency (for various reasons).

Intermernet• 12 years ago

Firstly I find it amazing that people would argue against "Evidence Based Medicine" at all. Isn't the alternative "Medicine without a shred of evidence that it works"? Why would that even deserve the name "medicine"?

Secondly, I find it scary that there is so much tip-toeing around charlatans selling snake oil. It seems similar to when the British Chiropractic Society sued Simon Singh [1] for libel, and then had to back down as they couldn't actually prove that chiropracty was at all based on scientific evidence. These scammers need to be called out and challenged. If you want to sell something as "medicine" (at least in the USA) it had better get FDA approval [2], and classification as a "drug". Although this approval process still leaves the onus for testing on the drug developer, it also provides a means for FDA dis-approval if the drug is subsequently found to be dangerous or ineffective. Not perfect, but better than nothing.

I really feel that science and evidence are losing in this battle due to the lack of PR and marketing. Last year saw the release of a few major studies showing the lack of strong evidence for the efficacy of multivitamins [3]. This hasn't stopped almost everyone I know from still buying and popping those pills all the time.

[1] http://en.wikipedia.org/wiki/BCA_v._Singh [2]: http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugs... [3]: http://www.medicaldaily.com/vitamins-and-supplements-waste-y...

glenra2• 12 years ago

Firstly I find it amazing that people would argue against "Evidence Based Medicine" at all. Isn't the alternative "Medicine without a shred of evidence that it works"?

You're reading too much into the name. Suppose I discover that whenever I eat carrots I get a horrible rash the next day. I track it carefully and find the effect is 100% reproducible. Eat carrots for a week, have a rash for a week; stop eating carrots for a week, it goes away. Eat them again, it comes right back. I cycle several times, the effect persists.

That is pretty powerful evidence that the right medicine for my rash is to avoid eating carrots. But this sort of knowledge doesn't count as "evidence" under EBM because it wasn't part of a massive random controlled trial. And it never COULD count as evidence under EBM because nobody can profit by the advice "stop eating carrots" enough for it to be worth doing a massive placebo-controlled random trial - "not eating carrots" can't be patented.

So long as FDA-type drug tests are ridiculously expensive, there is bound to be a LOT of perfectly valid medicine that IS evidence-based - there's evidence for it - but doesn't count as "evidence based medicine" according to the EBM enthusiasts.

Fighting Against Evidence

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