Evidence & EBM

Oct 03, 2011

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Epistemology and evidence based medicine

I dislike with a rare intensity much, if not all of the Evidence Based Medicine (EBM) movement. What started off as an important idea, namely that you cannot usefully predict from model systems up to man in a clinical context, has been hopelessly corrupted by a group with little knowledge of experimental science or statistics. Whereas ignorance in one of these areas is compatible with winning a Nobel prize, the combination is fatal. I would add that they seem to know little medicine either. I have written several articles on this theme. Most of such work is a matter of logistics and could usefully be outsourced to Amazon or Tesco: it does not belong in the Universities.

My first into this were two articles that I am actually quite proud of published in the Journal of the American Academy of Dermatology. They are here and here.

I have tended to polemic on this topic but the issues are really serious, and of course much of what the EBM tyros ramble on about is outwith conventional habits of rationality. Many young doctors and medical students have little understanding of how knowledge is acquired and are effectively brainwashed by people who think you can ‘trial’ your way out of any attempt to understand the natural world. On the other hand there is a group of medical establishment figures who seem blissfully unaware of the battle that philosophers have wrestled with for centuries over how one can arrive at reliable knowledge. There is this enormous irony in that many of the EBM icons see themselves as antiestablishment figures, whereas in reality they have — to borrow some phrases from Chomsky — become the commissars of a state bureaucracy. One only has too look at the dismal state of health economics and who funds it to see what is going on.

I wrote a piece trying to place the role of summary and numerical evidence about psoriasis management in a clinical framework here. Some other pieces are here and here.

Finally I wrote up a lecture (where the audience sadly seemed to sit on their hands at a dermatology conference) about the dominant ideological framework surrounding evidence — namely theindustrialisation of medical practice, and a piece where I try and flesh out why much outcomes research would be better done by Amazon than by University staff.

Post by Jonathan Rees

Clinical academic and skin watcher at the University of Edinburgh

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