Evidence-Based Medicine: A Great Idea. Can't Wait

So I caught a little flack from one of my colleagues about my post on placebo use in fibromyalgia. (My blog is anonymous, but my friends and colleagues are in the know.   Keeps me honest.)  In particular, he didn't like my reference to the "tyranny of evidence-based medicine".  In retrospect, with no context,  this statement could easily come from any Luddite anti-science rube of which there are many out there.  In fact, I am a card carrying member of the science-is-good club.  I am fully vaccinated, as are my children,  and have a tiny Darwin doll  on my dresser, although my wife tries frequently  to find it a less conspicuous mantle.  I also believe that for clinical medicine, controlled blinded studies have got us where we are and will take us a lot further.  My reference to the tyranny referred to the practitioners, not the practice.

When I was a resident, there was a huge shift away from basic research to clinical research.  The best and the brightest were signing up for Masters programs in public health or epidemiology, rather than considering bench research.  This, of course, was for the better as far as clinical research is considered and the move increased the general knowledge of epidemiology amongst the entire medical profession.  I was, like most, of the belief that solid clinical trials would be able to solve all of the big questions in medicine, given time, money and more money. We were taught to believe that any treatment that hadn't undergone the scrutiny of a double-blinded study was next to worthless.  In practice, this was rather nuts because most of what we did in a day did not have the necessary epidemiological blessing, but what it did was to further lower the esteem of clinicians in the university setting.  I recall seeing residents question senior staff decisions because of the lack of data on the matter.  Not that there was data against the opinion, simply that the data didn't exist.  It seemed that clinical experience was worthless, even in the absence of trial data to the contrary.  I'll admit, I was one of those residents.

    Real life was therefore a bit of a shock.  When you have to actually treat patients, you find that a lot of the evidence in evidence-based medicine is lacking.  I could simply catalogue the shortcomings of clinical trials, but in short:

     Patients in clinical trials are not like the ones in my office.  My patients are often a lot sicker, many with cancer, heart disease or other problems that the trial patients don't have.  They have a lot more pills from other doctors and really don't want the other four or five I'm suggesting.  They actually have to pay for their treatments, for long periods of time.  Sometimes they are just anti-pill, sometimes scared of needles. Disability and work issues are huge. Often, the epidemiologically approved treatments are exhausted early in our relationship, but the relationship goes on for years.  

Most of the common problems out there do not have adequate clinical trial evidence.  The rare diseases, orphans they are often called, have few studies and little hope of being seriously studied in the near future. 

Many, if not most of the trials are funded and often managed by the pharmaceutical industry, with all that that entails. (And it entails a lot)

Acupuncture, sham or otherwise and other even weirder practices still manage to produce positive studies which get published in peer-reviewed journals.  Yes, there are many possible reasons to explain this, but there you have it, and what do you do with it.

I'll stop here before it becomes a rant, or am I too late?  What I do know is that evidence-based medicine, at least in  clinical rheumatology, is just a really good idea.  Just don't pretend that there is enough epidemiological evidence out there to get me through my day. 

    

Comments

[PaulMD]

Great post. I agree, we don't have the piles of evidence that is available to other fields such as cardiology. You make a great point in saying that there isn't enough evidence out there to get through the day. I couldn't agree more, especially in rheumatology.

[3+speckled]

Thanks. I wonder though whether the cardiologists, on seeing the Jupiter/Crestor study, would prefer a little less evidence. Fortunately the biologics have brought research money into our field and perhaps there will be a trickle down to the more pharma-challenged diagnoses.