November 20, 2006

The limits of Evidence-Based Medicine

The parachute has not been properly tested to the same degree as evidence-based medicine (EBM)!

BMJ 2003;327:1459-1461 (20 December), doi:10.1136/bmj.327.7429.1459
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials

Study selection: Studies showing the effects of using a parachute during free fall.

Main outcome measure: Death or major trauma, defined as an injury severity score > 15.

Results: We were unable to identify any randomised controlled trials of parachute intervention.

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.

I got a good chuckle out of reading this. Basically, common sense must prevail over rigid adherence to scientific evidence, development of clinical criteria and other objective quantities. Sometimes EBM can project a total ignorance of human qualities... and I feel that this is the main problem underlying EBM's tense relationship with complementary and alternative medicine (CAM).

EBM and CAM both have the same objectives in mind -- they make the patient feel better. However, one of them demands PROOF. The other just cares if it makes you, the patient, feel better. As it has been shown time and time again, there is a degree of efficacy in placebo, where the mind actually is able to make the body feel better with a useless remedy. The placebo effect is a great friend to CAM adherents, because these people feel like they are regaining some control over their lives and their condition -- in doing something (even if it is nothing) they feel better.

Do EBM and CAM get along harmoniously? No. Do they have to? I don't think so. Orac, the EBM atheist/surgeon and full-time woo-hater, abhors the idea that medical schools have CAM in their curriculum. Even worse, AMSA, the premier med student organization, supports the woo.

I can see why this would trouble him. However, after participating in a retreat with the CAM department at my medical school this past weekend, I am not inclined to take the same hard line that Orac puts us up against. We spent very little time learning about the native medicine. (Which bothered me a lot.) We spent a lot of time learning about the native culture. (Which I have come to realize is the most important part of medicine that we cannot be taught through school.)

I think that it is vital to have CAM in medical school. We shouldn't be "so open-minded that our brains fall out," but at the same time, we need an understanding of these alternative medicines and the culture underlying them so we can be appropriate advisors. We care for the patients and obviously, they care for themselves because they ARE SEEKING TREATMENT... even if it is something that is not science-tested, doctor-approved.

In order to address CAM issues in the clinic, it is important to understand their theories and be accepting, not distainful. (Bedside manner is key!)

It is important to separate the roles of researcher and physician. It is the job of a scientist to be a skeptic -- and a doctor's role is to care. If someone takes their loved one to a reflexologist instead of a doctor with a complaint of "breast lumps" doesn't mean that they are loved any less. It doesn't mean that they are trying to prove something by being different. It does mean that you have to be respectful of their beliefs to regain their trust.

While your opinion is good and you think that it is right... it means nothing if patient has a different opinion of you and allopathic EBM.


  1. I don't have the patience at this point to touch upon your poor logic throughout this post but I will focus on one thing that I feel is vital. In order to allow society to excell to its fullest potential everybody should be a skeptic, but at the very least anyone who provides health care must approach their actions with a critical mindset.

    I'll try to return soon to say more on the bulk of this post but my 2 year old has a diaper full of crap and my Final Fantasy XII characters need some attention. I'm a skeptic, I never said I was cool.

  2. I agree with everything you say, clark. I am a skeptic too... but I am trying hard to learn to have faith in faithful, who feel that skepticism undermines belief. (And "messes up" a treatment that would have worked... if they only believed.)

    However, there is a difference between a personal philosophy and a general practice. I am learning that being a good doctor means sometimes, you can't be critical of your patients! Everyone has their own beliefs and it has been a big struggle for me to learn to appreciate ways of thinking that do not coincide with my own.

    There is a difference between positive feedback and negative criticism. If I were to disparage someone because they were wasting money on ineffective treatments, would they bother to tell me about their treatments that might be downright dangerous and contraindicated with conventional medicine? I think not.

    CAM should be approached seriously from a cultural and societal context, even if so much of it is flawed from a scientific perspective. Many CAM treatments are based on suppositions, theories and wacky hypotheses, which I find fun in a fantasy-fantastic sense. In contrast, EBM is slow, clunky, traditional and time-consuming, so it's no wonder that some people prefer to educate themselves on alternatives.

    Being able to speak respectfully and intelligently about CAM is not a flaw... rather, I see is as an asset in good medical practice.