Over the last decade of so there has been something of a propaganda war waged on behalf of “Evidence Based Medicine”.
I am generally in favour of this: there is far too much time and money wasted. I am in favour of getting people as healthy as possible as quickly as possible.
So Evidence Based Medicine seems to be clearly sensible. Who could argue against it? Well, me – partly.
When looked at closely Evidence Based Medicine has some weaknesses (as well as very great strengths). The weaknesses aren’t widely understood so I would like to draw attention to them here.
Firstly, there is what gets researched (and so has evidence to back it).
Imagine that I believe that eating garlic at 10am each morning will cause my neighbour to eat toast at midday. A sceptic will point out (quite rightly) that there is no evidence for this. And why not? Because no one (I hope) is loony enough to take this seriously. My point is that what gets researched – and so has a chance to become evidence is filtered. It is filtered through what is ‘common-sense’ to those doing research.
But what we regard as common-sense turns out to be flawed. The findings of sub-atomic physics are a cliché for how common-sense has been confounded. Likewise it is not common-sense to believe that pensioner bus passes are part of health policy (but they are: see Michael Marmot’s The Status Syndrome). And there is (now) very good evidence to say that they are.
This leads to the second difficulty with the evidence in Evidence Based Medicine. The evidence admitted is based on clinical trials – and these are expensive.
This means that the evidence is largely produced by government and very large corporations. Much of the research is directed to finding solutions that will make money (pills and so forth).
Most seriously this means that the diseases of the poor are not often studied and there is little research on them. Even the extraordinary amounts of money given by such philanthropists as Bill and Melinda Gates’ Foundation are only a tiny drop in the bucket.
In the ‘developed countries’ this means that low cost solutions – and pills that can’t be patented – receive less attention. Henry Osiecki has done huge amounts of research on treating medical problems with foods – but you probably haven’t heard of him (google him to find lots of stuff).
There is good evidence based research now (often thanks to universities) that shows things like: going for a walk is as good a treatment for depression as some drugs. And yet the pills are still more frequent than walking clubs.
Just because the evidence is there doesn’t mean that it will be acted on.
This is a third difficulty for evidence based medicine. It won’t necessarily change anything. This may be unfair – it’s not researches’ job to change things. But its advocates do want it to change how medicine is done. So this isn’t so much a criticism as just saying that it can’t do everything. It needs to be married with political savvy as well.
This leads to the fourth difficulty.
What we find convincing is our experience. If evidence from thousands of others says otherwise, well, we may change our minds. On the other hand we may not. We pay for more attention to those close to us than anonymous people far away. And clinical studies by their nature are about anonymous people we have had no contact with.
This is especially an issue for communication. The findings of the research could be communicated well – having individuals tell their story for instance, instead of in dry statistics.
However it is also a problem that this kind of research finds it hard to take account of all the complications of human experience.
Which leads to the fifth difficulty.
What research findings actually mean. “Cause” doesn’t mean quite the same in research as in normal speech. Perhaps the most popular example is: smoking causes cancer. This is a very solid research finding. However it doesn’t mean that if you smoke a cigarette you will get so much cancer and if you smoke lots of cigarettes you will get lots of cancer. What it means is that if you smoke a bit you are more like to get some health problems (lung cancer being only one) and if you smoke lots you are much more likely to get one of these health problems. It does NOT mean that you will – it just means that it is very likely. And we probably all know people who have defied the odds. (And we often forget all those who haven’t.) In our normal conversation when we say ‘cause’ we mean something pretty direct: the hammer hitting my thumb caused pain. In research – and so in Evidence Based Medicine – it’s a bit more complicated.
The final difficulty I want to point out is that Evidence Based Medicine is conservative.
The validity of the medicine is based on what has already been proven. If we were to go by only what has been proven we wouldn’t do any research at all. Any new ideas can’t be backed by research.
Evidence Based Research is advocated by well entrenched interests and operates to preclude those with new ideas. The conservative can always say to the innovators that there ideas are not proven: this is in the nature of the case. And why should people ‘waste’ time and money (which are always in short supply) trying something unproven? It seems an unanswerable argument. But the answer is that this is exactly what is required if we are to make any progress at all in any kind of research.
I am not trying to say that Evidence Based Medicine is of no value. It is of very great value. However it does have shortcomings – especially when dealing with anything beyond the mainstream. I hope with this in mind we can have a realistic appreciation of Evidence Based Medicine’s very great strengths.
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