Tarnished Gold: The Sickness of Evidence-Based Medicine.
|Article Type:||Book review|
|Subject:||Books (Book reviews)|
|Author:||Arnett, Jerome C., Jr.|
|Publication:||Name: Journal of American Physicians and Surgeons Publisher: Association of American Physicians and Surgeons, Inc. Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2012 Association of American Physicians and Surgeons, Inc. ISSN: 1543-4826|
|Issue:||Date: Summer, 2012 Source Volume: 17 Source Issue: 2|
|Topic:||NamedWork: Tarnished Gold: The Sickness of Evidence-Based Medicine (Nonfiction work)|
|Persons:||Reviewee: Roberts, Hilary; Hickey, Steve|
Tarnished Gold: The Sickness of
Evidence-Based Medicine, by Steve
Hickey and Hilary Roberts, paperback, 342
pp. $39.95, ISBN 978-1466397293,
"EBM erodes the autonomy of the physician and restricts patient choice." "EBM is junk science.... It has no underlying rational structure.... There is little, if any, prospect of a rational defense of its methods."
"Unlike EBM, science does not rely on reaching a consensus."
Steve Hickey and Hilary Roberts
Over the past several decades a marked change has occurred in the science used in medicine. The change has had consequences for patients and for our ability as physicians to practice effective, rational medicine. It has led to the use of evidence-based medicine (EBM) with its reliance on statistics, large clinical trials, and meta-analyses.
EBM was introduced around 1991, and the following year the Journal of the American Medical Association launched EBM as a new initiative. Soon the British Medical Journal and its editorial staff promoted it, and it was accepted by the British National Health Service. In this country, laws have been proposed in a number of states to require its use.
EBM has been promoted as a panacea at the expense of medical science, yet it never has been subjected to empirical testing. It exists in a world where epidemiologists and statisticians have risen from technical support to become arbiters of medical science.
Many physicians have discredited its validity over the past 16 years, notably Dr. Bruce Charleton of Newcastle University, UK, and Dr. Martin Tobin of Loyola University, Chicago. The EBM controversy was featured in a 2008 point-counterpoint editorial in Chest, the Journal of the American College of Chest Physicians. It has been spoofed as Eminence-based, Vehemence-based, Eloquence-based, Providence-based, Diffidence-based, Nervousness-based, and Confidence based Medicine.
Although many intelligent, well educated people still believe in EBM, their faith is based on an illusion. In Tarnished Gold, authors Steve Hickey, Ph.D., and Hilary Roberts, Ph.D., challenge EBM's accepted claims of providing "scientific proof" and "gold standard" methods. The authors show that EBM removes the critical authority in medicine from the decision making skills of the physician, that it harms patients and suppresses medical progress, and that it suffers from a series of fundamental errors that make it both irrational and unscientific.
EBM is widely defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients, "where" best evidence" is not defined. But as the authors note, in scientific medicine there is no such thing as "best evidence"; there is only information, and information is not the same as knowledge or wisdom.
To show why EBM is wrong, Hickey and Roberts explain the use of statistics and probability, describe the difference between accuracy and precision, and show how to use a decision tree. They discuss the scientific method and the use of Bayes's theorem and describe the proper role of the clinical trial. They explain the problem of bias in the use of "best evidence" and describe the curse of multiple risk factors in epidemiological studies. They also show why correlation is not the same as causation, why evidence is not the same as expertise, and why meta-analysis is unscientific, biased, and irrational.
EBM is based on epidemiology, which is the study of disease in populations. But a population value, from group statistics, cannot be applied to an individual patient. Group averages tell us nothing about the individuals who are in the group. This statistical blunder, the ecological fallacy, has been recognized for many years and has been well documented in the literature.
Another problem with EBM is its reliance on the large clinical trial. EBM defines the clinical trial as, "a well-designed large-scale, double-blind, randomized, placebo-controlled, [clinical] trial." The authors assert that most of these large trials are wrong and that they often find clinically unimportant results that lead to ineffective treatments.
EBM wants to cure the autonomy and authority of the physician and the subsequent variability in care, but according to the authors, in practice it creates a rule-based approach where the freedom of physicians to treat their patients is inevitably compromised. It condemns the experience and observations of physicians as anecdotal.
The authors illustrate how this can harm patients with two examples of a major medical advance that repeatedly has been rejected by mainstream medicine. In 1949, in the midst of a polio epidemic, Dr. Frederick Klenner, a family physician in North Carolina, reported at an annual meeting of the American Medical Association that he had cured 60 acute polio patients with massive doses of parenteral vitamin C. All recovered quickly without sequelae. Not one died or even developed any paralysis. At least eight other physicians have since confirmed his results.
Their second example is the incredible story of Allan Smith, a 56-year-old New Zealand farmer who contracted a severe case of swine flu in 2009 and was given Tamiflu. His condition rapidly deteriorated, and he developed pneumonia. He was placed on extracorporeal membrane oxygenation (ECMO) for three weeks. At that point the hospital insisted on terminating his life support. His physicians refused the family's request to give parenteral vitamin C. (It was not an "evidence based" treatment.) But the family persisted and intravenous vitamin C was given at 50 grams twice daily for six days. His lung function rapidly improved, and ECMO was stopped on day 5. He began breathing without a ventilator. But the vitamin C was then stopped, and his condition quickly worsened. The family had to hire a lawyer before his physicians would resume the vitamin C treatment. Smith eventually recovered completely and returned to farming.
Finally, the authors explain how EBM's statistical approach provides a legal framework that supports management and governance of medicine and encourages totalitarian medicine. As they point out, its greatest value is for governments, corporate medicine, and the medical establishment--not for practicing physicians.
As Dr. Tobin has noted, utopian projects aimed at eradicating uncertainty and introducing good have produced more misery than good fortune. Tarnished Gold exposes EBM as a costly failure. Physicians and the public should hold the medical establishment, public health professionals, epidemiologists, and health economists responsible. Eliminating the scourge of EBM from our profession will save money and lives, and improve our health.
Jerome C. Arnett, Jr., M.D.
|Gale Copyright:||Copyright 2012 Gale, Cengage Learning. All rights reserved.|