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Evidence Based Medicine - some critiques incl. one calling it a "Zombie Science"

Dolphin

Senior Member
Messages
17,567
Zombie science of Evidence-Based Medicine
The Zombie science of Evidence-Based Medicine (EBM): a personal retrospective

Bruce G Charlton. Journal of Evaluation in Clinical Practice. 2009; 15: 930-934.

Professor of Theoretical Medicine
University of Buckingham
e-mail: bruce.charlton@buckingham.ac.uk

Full free text at: http://charltonteaching.blogspot.com/2009/08/zombie-science-of-evidence-based.html

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The evidence-based medicine model of clinical practice: scientific teaching or belief-based preaching?

J Eval Clin Pract. 2011 Aug;17(4):597-605. doi: 10.1111/j.1365-2753.2010.01562.x. Epub 2010 Nov 18.

Charles C, Gafni A, Freeman E.

Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. charlesc@mcmaster.ca

RATIONALE: Evidence-based medicine (EBM) is commonly advocated as a 'gold standard' of clinical practice. A prominent definition of EBM is: the integration of best research evidence with clinical expertise and patient values. Over time, various versions of a conceptual model or framework for implementing EBM (i.e. how to practice EBM) have been developed.

AIMS AND OBJECTIVES: This paper (i) traces the evolution of the different versions of the conceptual model; (ii) tries to make explicit the underlying goals, assumptions and logic of the various versions by exploring the definitions and meaning of the components identified in each model, and the methods suggested for integrating these into clinical practice; and (iii) offers an analytic critique of the various model iterations.

METHODS: A literature review was undertaken to identify, summarize, and compare the content of articles and books discussing EBM as a conceptual model to guide physicians in clinical practice.

RESULTS: Our findings suggest that the EBM model of clinical practice, as it has evolved over time, is largely belief-based, because it is lacking in empirical evidence and theoretical support. The model is not well developed and articulated in terms of defining model components, justifying their inclusion and suggesting ways to integrate these in clinical practice.

CONCLUSION: These findings are significant because without a model that clearly defines what constitutes an EBM approach to clinical practice we cannot (i) consistently teach clinicians how to do it and (ii) evaluate whether it is being done.

PMID: 21087367
One might be able to find the full text of this if one searches around the site.
 

Dolphin

Senior Member
Messages
17,567
I read the Charlton and Charles et al. papers yesterday.

The Charlton paper is quite good in terms of showing how EBM might be maintained/grow. However, I found it didn't give many details about where the problems with EBM lie except that at an individual level, "average" results from RCTs might not be the best for any individual patient. It would be good if examples of the problems with this sort of thinking (treat the patients the same basically) were given.

I had been slightly wary of the term Zombie Science before this as it seemed quite dramatic and perhaps over the top/would seem that way. But am more thinking now that it might be justified.

Some quotes from the Charlton paper:

I recently delineated the concept of Zombie science [5], partly based on my experiences with EBM, and the concept has already spread quite widely via the internet. Zombie science is defined as a science that is dead but will not lie down. Instead, it keeps twitching and lumbering around so that it somewhat resembles Real science. But on closer examination, the Zombie has no life of its own (i.e. Zombie science is not driven by the scientific search for truth [6]); it is animated and moved only by the incessant pumping of funds. Funding is the necessary and sufficient reason for the existence of Zombie science; which is kept moving for so long as it serves the purposes of its funders (and no longer).

So it is a waste of time arguing against Zombie Science because it cannot be stopped by any method except by cutting-off its fund supply. Zombie science cannot be killed because it is already dead.
I can see that with all the CBT studies that are churned out by Nijmegen for example. They keep coming up with ways to present the data as a success even though their own studies showed the patients' activity levels didn't increase over the control levels. It also happens to an extent in the UK with all the studies that are churned out there. And all the funding such researchers can get.

With regard to best evidence there was the assertion that evidence meant only focusing on epidemiological data (and not biochemistry, genetics, physiology, pharmacology, engineering or any other of the domains which had generated scientific breakthroughs in the past). It meant ignoring the role of tacit knowledge derived from apprenticeship. And it was clearly untrue [12-15].
I think this is interesting given how little discussion there can be about biological matters in the ME/CFS field. The Lancet PACE Trial, a substantial paper, doesn't mention biology at all.

In killing-off the bottom-up ideals of Clinical Epidemiology, EBM embraced a top-down and coercive power structure to impose EBM-defined best evidence on clinical practice [20, 21]; this to happen whether clinical scientists or doctors agreed that the evidence was best or not (and because doctors have been foundationally branded as prejudiced, conservative and irrational EBM advocates were pre-disposed to ignore their views anyway).

Expertise was arbitrarily redefined in epidemiological and biostatistical terms, and virtue redefined as submission to EBM recommendations so that the job of physician was at a stroke transformed into one based upon absolute obedience to the instructions of EBM-utilizing managers [3].

(Indeed, since too many UK doctors were found to be disobedient to their managers; in the NHS this has led to a progressive long-term strategy of the replacing doctors by more-controllable nurses, who are now first contact for patients in many primary and specialist health service situations.)
I think a reason/another reason why such a system likes nurses and generally "non doctors" is because they can't prescribe many drugs (and the oens they can are usually only fairly cheap ones) nor can they order tests generally. So cheaper, along with making it easier to estimate what the budgets will be.

EBM did not need to be a science or a scientific methodology, because it was not adopted by scientists but by politicians, government officials, managers and biostatisticians [3]. All it needed scientifically was to look enough like a scientific activity to convince a group of uninformed people who stood to benefit personally from its adoption.

Suddenly the Zombie science of EBM was everywhere in the UK because money-to-do-EBM was everywhere and modern medical researchers are rapidly-evolving organisms which can mutate to colonize any richly-resourced niche unhampered by inconveniences such as truthfulness or integrity [23]. Anyway, when existing personnel were unwilling, there was plenty of money to appoint new ones to new jobs.

Nor was it merely the replacement of the bottom up model of Clinical Epidemiology with the authoritarian dictatorship which EBM rapidly became.

No, EBM was much more radically different from Clinical Epidemiology than merely a change of name and an inversion of authority; because the new EBM sprang from the womb fully-formed as a self-evident truth [3, 4]. EBM was not a hypothesis but a circular and self-justifying revelation in which definition supported analysis which supported definition all rolled-up in an urgent moral imperative. To know EBM was to love him; and to recognize him as the Messiah; and to anticipate his imminent coming.

In short, EBM was never required to prove itself superior to the existing model of medical practice; rather, existing practice was put into the position of having to prove itself superior to the newcomer EBM!

So EBM was never required to prove with evidence what it should have been necessary to prove before beginning the wholesale reorganization of medical practice: i.e. that EBM was a better system than whatever we like to call whatever went before EBM.

But how could this happen? why was it that the medical world did not merely laugh in the metaphorical face of this pretender to the crown? The answer was money, of course; because EBM was proclaimed Messiah with the backing of serious amounts of UK state funding.

Compared with learning a Real science, it was facile to learn the few threads of EBM jargon required to stitch-together your own Zombie skin using bits and pieces of your own expertise (however limited); then along would come the UK government and pump this diaphanous membrane full of cash to create a fairly-realistic Zombie of pseudo-science. In a world where scientific identity can be self-defined, and scientific status is a matter of grant income [11], then the resulting inflatable monster bears a sufficient resemblance to Real science to perform the necessary functions such as securing jobs or promotions, enhancing salary and status.

The fact that EBM was based upon pure and untested assertions therefore did not weaken it in the slightest; rather the scientific weakness was itself a source of political strength. Because, in a situation where belief in EBM was so heavily subsidized, it was up to critics conclusively to prove the negative: that EBM could not work. And even when conclusive proof was forthcoming, it could easily be ignored. After all, who cares about the views of a bunch of losers who cant recognize a major funding opportunity when they see it?

Nowadays EBM means whatever the political and managerial hierarchy of the health service want it to mean for the purpose in hand. Mega-randomized trails are treated as the only valid evidence until this is challenged or the results are unwelcome, when other forms of evidence are introduced on an ad hoc basis.

[..]
But a measure of success is that the NHS hierarchy who use the EBM terminology are the ones with power to decide its official meaning when deployed on each specific occasion.
- I think this is particularly interesting. That, say, with the NICE guidelines, or when some other guidelines are being drawn up, some evidence for or against CBT/GET or the alternatives can be seen as acceptable or unacceptable (sufficient/insufficient or good quality/not good quality) as it suits them.
 

Dolphin

Senior Member
Messages
17,567
I'm not sure if I have the time to post up all my notes on the Charles et al paper. It isn't a polemic like the Charlton piece.

It shows how the EBM model has changed over the years. How many aspects of it are unclear.
In particular, it's unclear how much weighting to give to the different aspects that make up the model.

At the moment they are:
- Clinical state, setting and circumstances
- Patient preferences and actions
- Research evidence
- Health care resources
- Clinical Expertise
(the paper talks also about how some of these aren't always well-defined or the definition changes).

I found it interesting that "Patient preferences and actions" (or "Patient preferences") are part of it - they don't seem to play a major role in say the UK, Belgian or Dutch (? - don't know as much about the Netherlands) models of care. And with the PACE Trial and other discussions, patient organisations are often criticised - even though they are often simply giving patient opinions.
 
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I found it interesting that "Patient preferences and actions" (or "Patient preferences") are part of it - they don't seem to play a major role in say the UK, Belgian or Dutch (? - don't know as much about the Netherlands) models of care.

In the Netherlands I had the choice of going to Nijmegen (hahahahahahaha) for CBT or to a real ME/CFS clinic in Lelystad. I also could have requested a referral to one of the other clinics, including one that's apparently just doing research and not much treatment in Amsterdam.
 

Dolphin

Senior Member
Messages
17,567
In the Netherlands I had the choice of going to Nijmegen (hahahahahahaha) for CBT or to a real ME/CFS clinic in Lelystad. I also could have requested a referral to one of the other clinics, including one that's apparently just doing research and not much treatment in Amsterdam.
Thanks, Valentijn, that's good to know. I have the odd bit of interesting research from the Netherlands e.g. by Vermeulen, but wasn't sure if they were available as part of the public system or not.