Rethinking Evidence-Based Medicine: from rubbish to real
January 21, 2014
Trish Greenhalgh, an EBM critic, recently challenged Carl Heneghan on Twitter to promote real EBM, as opposed to the rubbish version. In response Carl proposed a meeting, for which I had the great pleasure (and stress!) of facilitating. There were quite a few EBM bigwigs, and as @mgtmccartney noted, the room was full of heroes such as Druin Birch, Jon Brassey, Martin Burton, Hasok Chang, Iona Heath, Richard Lehman, Mike Kelly, Neal Maskrey, Margaret McCartney, Rory Milne, and Des Spence. Details have been storified on Twitter so I won’t repeat them here.
To me (and not necessarily others in the group) the meeting revealed serious problems:
- Too much evidence is flawed (out of date, financially conflicted, and suffering from publication bias).
- This flawed evidence is used (often via guidelines) as a stick to beat clinicians. If your doctor doesn’t follow the guideline (even if you and your doctor don’t think it is best) the doctor risks being accused of malpractice and having their picture on the cover of the newspaper. For example the entire population is being ‘statinized’ in spite of little evidence for benefit (apart from those who have had heart attacks). Using guidelines as sticks for beating clinicians takes away patient choice, prevents critical thought, and hinders doctors’ ability to care for patients.
- Evidence (good and bad) is presented in a way that doctors and patients do not understand. Tiny effects are misleadingly represented as (seemingly larger) relative effect sizes. This leads to vast overuse of drugs such as statins.
To add insult to injury, producing this flawed evidence costs billions of dollars and millions of hours to produce.
But all clouds – even the big ones revealed at this meeting – have silver linings. Besides the problems, the meeting and its reaction demonstrated that there are many energetic people committed to real EBM because they care deeply about patients.
If you would like to help promote real and not rubbish EBM watch this space, The meeting was only intended to be a small first step and more will follow. (And if you haven’t signed up to the alltrials campaign do it now.)