Evidence Based Medicine is one of those things that is a good thing, but was pushed so hard by its proponents that it ended up overemphasizing a particular kind of study as the only real way to know things in medicine.

Yes, absolutely, medicine should be evidence based. Yes, large randomized, double blind, placebo controlled studies provide a lot of information.

However, there are limitations with these kinds of studies.

First, it may not be ethical or practical to study some things in this manner. For example, antibiotics for bacterial pneumonia has not had a randomized, double blind, placebo controlled study.

Famously, there was an article discussing how parachutes in jumping out of airplanes had not been subject to a randomized, double blind, placebo controlled study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/

Later, somebody did that study: https://www.bmj.com/content/363/bmj.k5094 and found that parachutes made no difference, but it is not applicable to any real world case where you would use a parachute.

Which illustrates the second issue with evidence based medicine. Many times, the large trials's main thing they are measuring are different than what you really want to know, or the population they studied has significant differences from the patient who is right in front of you. How to apply the results of the large study to the individual patient in front of you is still more of an art than a science.

Finally, I think there is the example from machine learning. It has turned out that instead of creating more and more rules, feeding lots and lots of data to a neural network ends up performing better in a lot of machine learning cases. In a similar way, an experienced physician who has treated thousands of patients over decades has a lot of implicit knowledge and patterns stored in their (human) neural networks. Yes, these decisions should be informed by the results of trials, but they should not be discounted, which I think that Evidence Based Medicine did in at least a small part. During my residency, I worked with physicians who would examine and talk with a patient and tell me that something is not right and to do more extensive tests which would end up unearthing a hidden infection or other problem that we were able to treat before it caused major problems. They were seeing subtle patterns from decades of experience that might not even be fully captured in the patient's chart, much less a clinical trial without thousands of participants.

So yes, these clinical trials are a very important base for knowledge. But so is physician judgment and experience.

Source: I am a physician.

The main flaw in EBM is that it inverts the scientific method: It’s no longer about hypotheses and falsification. Instead it’s about “scientifically proven facts” (aka “evidence”). Sadly this aligns much better with our dogmatic instinctive understanding of knowledge as a set of agreed truths.
There was a great book about Evidence Based Medicine, from a woman out of Oxford, I read a long while ago. Can't for the life of me remember the name, but Oxford does have a center for "Evidence Based Medicine," and the whole idea has been slowly coming back into fashion.

Instead, all I can recommend is a collection of essays -- loosely -- related to the subject: Where's the Evidence?, Silverman


On another note, someone who's gone down the pharmaceutical research rabbit hole and concluded a lot of it is "bunkum" (e.g. statins, anti-depressants, and so on), would do well to look into surgery next -- especially that of surgical implants.

Some of worth looking into: joint replacements, joint and spinal fusions, angioplasties.

Of note: spinal fusions were not brought about on any scientific or experimental bases, but on hunches from surgeons (damnable bunch). Many do result in a reduction in pain, but it does bring to question how much of it is simply "placebo." There were a few experiments in this realm of doing double blind (or single blind, it escapes me right now) studies on back surgeries, that showed evidence the placebo effect was involved. The simple act of being put under anaesthesia, and convinced one had gotten "treatment," resulted in reductions in pain for those who came in for spinal surgery.

I do wish more research would be done into the placebo effect, and doctors would stop faffing about in self-righteousness (though having an air of expertise and authority does impact the placebo effect positively). And I don't mean in a "the placebo effect exists and is usable as a treatment" way, but in a "the placebo effect exists, and here is how it works in the body." That would be very interesting. Long ago I read a few papers on the placebo effect in regulating blood pressure via regulation of a certain chemical (it could have been a hormone like renin, but I can't recall). At the time, I thought the autonomic nervous system would be a good avenue to research to better figure this out (it would be a convenient explanation for how the placebo effect works: activating the nerves in the kidneys via the cross-talk from the central nervous system to excrete certain hormones). If it can affect the kidneys, what other bodily systems can it impact? The possibilities are not endless, but rather exciting.

I believe the "placebo effect" is the reason chiropractors are so popular, in spite of there being no real physical evidence as to why their treatments help people.

Ah, the human as a specimen in a petri dish approach to so-called health care. Flies directly in the face of study after study after study that says: diet and lifestyle are major factors in all deadly diseases.

Probably driven by modern tech, completely inadvertently, because x-ray machines and MRIs and such demand that the patient go to the clinic or hospital rather than the doctor going to the patient's home.

Star Trek's Dr. McCoy and his tricorder was a dream of tech that you could carry in the proverbial little black bag. We aren't there and have forgotten a lot of important principles in the process of pursuing shiny tech.

But it's generally a bad idea to critique any of that. Gets one nothing but hatred.

Here is a 2022 critique of the narrow-mindedness of Evidence Based Medicine, by an Oxford professor and the author of what is perhaps the most widely used textbook on Evidence Based Medicine: https://ebm.bmj.com/content/27/5/253
Good lecture on this topic https://youtu.be/z6IO2DZjOkY
I'm a biochemist with a medical background, and FWIW, I think this is a garbage article. Hardly even worth commenting on.


(2020) Will COVID-19 be evidence-based medicine’s nemesis?


"It is surely time to turn to a more fit-for-purpose scientific paradigm. Complex adaptive systems theory proposes that precise quantification of particular cause-effect relationships is both impossible (because such relationships are not constant and cannot be meaningfully isolated) and unnecessary (because what matters is what emerges in a particular real-world situation). This paradigm proposes that where multiple factors are interacting in dynamic and unpredictable ways, naturalistic methods and rapid-cycle evaluation are the preferred study design. The 20th-century logic of evidence-based medicine, in which scientists pursued the goals of certainty, predictability and linear causality, remains useful in some circumstances (for example, the drug and vaccine trials referred to above). But at a population and system level, we need to embrace 21st-century epistemology and methods to study how best to cope with uncertainty, unpredictability and non-linear causality [16].

In a complex system, the question driving scientific inquiry is not “what is the effect size and is it statistically significant once other variables have been controlled for?” but “does this intervention contribute, along with other factors, to a desirable outcome?”. Multiple interventions might each contribute to an overall beneficial effect through heterogeneous effects on disparate causal pathways, even though none would have a statistically significant impact on any predefined variable [11]. To illuminate such influences, we need to apply research designs that foreground dynamic interactions and emergence. These include in-depth, mixed-method case studies (primary research) and narrative reviews (secondary research) that tease out interconnections and highlight generative causality across the system [16, 17]."

table1: https://journals.plos.org/plosmedicine/article?id=10.1371/jo...

I'd love the idea of science based medicine. There are a few issues:

>HIPPA has made it basically impossible to do science in Medicine without being part of the establishment

>The medical cartels hate change, its bad for business, they actively lobby against change and competition. They want authority based medicine.

>The scientist responsible for the discovery and treatment of an issue, can't even legally practice.

We should entirely be blaming the medical cartels here. They have been terrible for our health, technology, and wallets.

I am sure I miss the context but I guess the point is that authors were sick of hearing about the promise of statistical analysis and epidemiology which will outperform classical medical approach - slandering the BMJ several times for some reason.

Even today we see some hanger-ons who assert that their way is the best way - that they know from personal medical cases and their opinion and interpretation is more valuable than some statistical prediction.

Well, if I have understood their sentiment correctly; facts are facts. Today the best medical care in the world is driven by data-based adaption rather than subjective opinion. If a treatment has a robust statistical impact it will be preferred. If new methods produce outcomes no better than random noise then we must agree that they are not better. If the physician has anecdotes about why they think some trick works best then - in the words of Pearson - “statistics on the table, please”.

I am sorry to make the joke but it seems apt: “Dr Charlatan disgruntled about needing evidence for science”.

I thought all medicine is evidence based as long as it’s not homeopathic or chiropractic?