Where does the evidence come from?

The circulars which the Ministry Of Health (MOH) has sent to all clinics in Singapore call for all treatment to be “evidence based medicine”. Their definition of this concept has not been given.  One of the reference sources on the MOH website (Duke University, Introduction to Evidence-Based Medicine) gives us this definition from David Sackett, the founding father of the concept of evidence based medicine (bolding by HCS):

Evidence Based Practice (EBP) is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology.

(Sackett, D. (2002) Evidence-based Medicine: How to Practice and Teach EBM, 2nd edn. London: Churchill Livingstone.)

The Duke University website goes on (bolding by HCS):

The evidence, by itself, does not make the decision, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes and quality of life. The practice of EBP is usually triggered by patient encounters which generate questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, and/or the etiology of disorders.

http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021

The analysis below is taken from Evidence Based Practice, McGraw-Hill Education (bolding by HCS):

Sackett acknowledges and values the different types of knowledge held by the clinician, for example, knowledge acquired through cultural and personal experiences, logical and critical knowledge gained through curriculum and the extra insight that can only be acquired through cumulative clinical expertise. He values the patient as an empowered decision maker and highlights that not all research is transferable into practice due to flaws in either design or reason.

https://www.mheducation.co.uk/openup/chapters/9780335244737.pdf

Note that Sackett states that the best evidence is usually found in what the MOH would call “relevant research”. However, when the evidence found in laboratory tests is responded to with finely adjusted bioidentical hormone replacement (including desiccated thyroid) there is ample evidence available provided by well-respected doctors worldwide (some of it on this site) that patients are receiving the care they need and, further, the care that addresses “the patient’s unique concerns, expectations, and values”.

Interestingly Sackett refined his position. Taken from Too Many Experts Spoil The Science, 8 May 2000 (Bolding by HCS):

http://www.abc.net.au/cgi-bin/common/printfriendly.pl?/science/news/health/HealthRepublish_124166.htm

According to the founder of Evidence Based Medicine experts are hindering the healthy advancement of science. Writing in this week’s British Medical Journal (BMJ), Canadian-based researcher, David Sackett, said that he would “never again lecture, write, or referee anything to do with evidence based clinical practice”. Sackett is not doing this because he has ceased to believe in evidence based clinical practice but, as the BMJ comments, because he is worried about the power of experts in stifling new ideas and wants the retirement of experts to be made compulsory.

Sackett claims that the prestige of experts (including himself) gives their opinions far greater persuasive power than they deserve on scientific grounds alone. “Whether through deference, fear, or respect, others tend not to challenge them, and progress towards the truth is impaired in the presence of an expert,” he writes.

He also argues that expert bias against new ideas operates during the review of grant applications and manuscripts. “Reviewers face the unavoidable temptation to accept or reject new evidence and ideas, not on the basis of scientific merit, but on the extent to which they agree or disagree with the public positions taken by experts on these matters.

(Sackett’s article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118019/)

In response to this, Dr Malcolm Kendrick comments on his blog You Are Killing Patients:

My rather cynical view is that experts can be compared to those men (usually men) who have grabbed hold of the microphone at the front of a mob during a protest march. With this simple act they have managed to gain status and authority. Shortly after they become spokesmen for the revolutionary movement, then leaders…then despots.

However, most newspapers, journalists, television producers never ask they question, how did an expert become an expert – what makes them so. Instead, they are completely in the thrall of the ‘experts’, and greatly fear their power. Which means that when an eminent professor loads and fires the ‘you’re killing patients’ gun, all hell breaks loose and panic stalks the land. Journalists, newspaper editors, TV producers and suchlike quiver in fear. They instantly retract everything they have ever published on the matter, and promise never to do it again.

http://drmalcolmkendrick.org/2014/06/04/you-are-killing-patients/

The topic of evidence based medicine is one that stirs controversy. Surely the patient themselves should provide some of the evidence – if it works, and it hasn’t killed anyone, don’t ban it. If it works and I feel good on it, I want to continue using it. Recently there has been much debate about the safety of supplements. However, every year more than 106,000 people die from reactions to prescription medicine. The last year we have data for, which was 2013, the number of people who died from taking a nutrient was zero. Surely that is “evidence” of their safety, if not of their efficacy?

 

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Posted in Evidence Based Medicine, Mainstream Medicine.

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