January 29th, 2014
(written by lawrence krubner, however indented passages are often quotes). You can contact lawrence at: email@example.com
Interesting: This argument would be stronger if it had something to say about those cases where there is no known best practice. We all know there are some demographic segments are poorly served by the current medical industry. If a middle aged woman with mild but painful neurological symptoms goes to see her doctor, there is little the doctor can do for her and she will be lucky if the doctor takes her seriously. The reality is there are many illnesses of which no one knows the cause and clinical experimentation is the only rational way to deal with such unknown circumstances.
It’s rare to see a logical fallacy stated so overtly. Klein could not have crafted a better example of the Nirvana fallacy if he tried:
But we should only trust EBM if the science behind best practices is infallible and comprehensive, and that’s certainly not the case. Medical science is not infallible. Practitioners shouldn’t believe a published study just because it meets the criteria of randomized controlled trial design. Too many of these studies cannot be replicated. Sometimes the researcher got lucky and the experiments that failed to replicate the finding never got published or even submitted to a journal (the so-called publication bias). In rare cases the researcher has faked the results. Even when the results can be replicated they shouldn’t automatically be believed—conditions may have been set up in a way that misses the phenomenon of interest so a negative finding doesn’t necessarily rule out an effect.
Really – unless science is infallible and comprehensive, we should ditch it? Unless we have perfect knowledge of everything we should behave as if we know nothing?
This attitude is not new. It is common in the alternative world. It just usually isn’t stated so boldly.
Again, Klein points out legitimate problems with the institution of science in general, and evidence-based medicine in particular. Yes – there are biases, there are publication issues and failure to replicate. We spend a great deal of time on SBM pointing out and discussing all the various challenges to rigorous science.
Klein and others, however, want to throw the baby out with the bathwater – to ditch scientific evidence, rather than work toward improving it. All of the problems with science in medicine have potential solutions, and we are making progress.
Klein also falls for a very common myth about EBM:
EBM formulates best practices for general populations but practitioners treat individuals, and need to take individual differences into account.
Here he clearly demonstrates that he is not familiar with EBM (and therefore is not in a position to recommend its demise). EBM absolutely recognizes that evidence needs to be applied to individual patients, and that practitioners need to combine the best evidence with their own clinical experience and judgments. This is nothing but a false accusation based upon ignorance of EBM.
Klein goes further, saying that advances in surgical techniques do not need placebo controlled trials, therefore we don’t really need placebo-controlled studies.
He then concludes:
Worse, reliance on EBM can impede scientific progress. If hospitals and insurance companies mandate EBM, backed up by the threat of lawsuits if adverse outcomes are accompanied by any departure from best practices, physicians will become reluctant to try alternative treatment strategies that have not yet been evaluated using randomized controlled trials. Scientific advancement can become stifled if front-line physicians, who blend medical expertise with respect for research, are prevented from exploration and are discouraged from making discoveries.
This is a profoundly naïve position. Preventing practitioners from essentially experimenting in an uncontrolled way on their patients is a good thing. Best practices and the standard of care exist for a reason – and they are not only based upon the best evidence, but also expert analysis and experience.
Adherence to best practices strongly correlates with better outcomes. Over-reliance on experience and judgement in deciding on treatments can be counterproductive.
Further, experimenting needs to be done within a strict ethical and scientific framework. You cannot, for example, ditch the standard of care in order to go exploring.