[HN Gopher] The Rise and Fall of Evidence Based Medicine (1998) ...
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The Rise and Fall of Evidence Based Medicine (1998) [pdf]
Author : quickfox
Score : 61 points
Date : 2023-06-01 16:29 UTC (6 hours ago)
(HTM) web link (www.researchgate.net)
(TXT) w3m dump (www.researchgate.net)
| rgbgraph wrote:
| There was a great book about Evidence Based Medicine, from a
| woman out of Oxford, I read a long while ago. Can't for the life
| of me remember the name, but Oxford does have a center for
| "Evidence Based Medicine," and the whole idea has been slowly
| coming back into fashion.
|
| Instead, all I can recommend is a collection of essays -- loosely
| -- related to the subject: _Where 's the Evidence?_, Silverman
|
| ---
|
| On another note, someone who's gone down the pharmaceutical
| research rabbit hole and concluded a lot of it is "bunkum" (e.g.
| statins, anti-depressants, and so on), would do well to look into
| surgery next -- especially that of surgical implants.
|
| Some of worth looking into: joint replacements, joint and spinal
| fusions, angioplasties.
|
| Of note: spinal fusions were not brought about on any scientific
| or experimental bases, but on hunches from surgeons (damnable
| bunch). Many do result in a reduction in pain, but it does bring
| to question how much of it is simply "placebo." There were a few
| experiments in this realm of doing double blind (or single blind,
| it escapes me right now) studies on back surgeries, that showed
| evidence the placebo effect was involved. The simple act of being
| put under anaesthesia, and convinced one had gotten "treatment,"
| resulted in reductions in pain for those who came in for spinal
| surgery.
|
| I do wish more research would be done into the placebo effect,
| and doctors would stop faffing about in self-righteousness
| (though having an air of expertise and authority does impact the
| placebo effect positively). And I don't mean in a "the placebo
| effect exists and is usable as a treatment" way, but in a "the
| placebo effect exists, and here is how it works in the body."
| That would be very interesting. Long ago I read a few papers on
| the placebo effect in regulating blood pressure via regulation of
| a certain chemical (it could have been a hormone like renin, but
| I can't recall). At the time, I thought the autonomic nervous
| system would be a good avenue to research to better figure this
| out (it would be a convenient explanation for how the placebo
| effect works: activating the nerves in the kidneys via the cross-
| talk from the central nervous system to excrete certain
| hormones). If it can affect the kidneys, what other bodily
| systems can it impact? The possibilities are not endless, but
| rather exciting.
|
| I believe the "placebo effect" is the reason chiropractors are so
| popular, in spite of there being no real physical evidence as to
| why their treatments help people.
| LorenPechtel wrote:
| I do agree things should be studied but you have to be careful
| with it. Studies are big and expensive and things can be
| missed. Remember the big flap over hormone replacement therapy
| being shown harmful? Oops--all it really showed is what we knew
| all along, estrogen is risky for fat women.
| importantbrian wrote:
| What makes you conclude that statins are "bunkum"? I don't know
| anything about anti-depressants or surgical implants, but I
| have gone down the rabbit hole on statins and at least as far
| as I can tell they do what they are generally claimed to do,
| are safe, and so if you are at high risk for hear disease you
| should probably be taking them.
| rgbgraph wrote:
| In bullet-points:
|
| - Absolute risk reduction in CVD-caused mortality is mild at
| best (<1-2% absolute risk reduction)
|
| - Percentage of people that get side-effects is higher than
| the percentage of people that receive a benefit from statins;
| as well, the side-effects are rather serious in affecting QoL
| -- making them a poor choice as a long-term prophylactic
|
| - Generic lipid panels that the vast majority of people take
| are generally worthless for estimating lipid health: LDL
| "large particle -- bad" cholesterol is not actually measured,
| but estimated. The current formula is: (total cholesterol -
| HDL - triglycerides)/5 which is liable to under-report true
| LDL levels. Estimation also has the drawback of being unable
| to tell how much of each "bad" particle is actually in your
| blood (chylomicrons vs VLDL vs LDL etc.) -- muddying your
| actual risk profile. Likewise, no LDL "content" tests are
| performed to measure how much cholesterol each LDL is
| actually carrying. So yes, statins will lower these numbers,
| but the methodology around these numbers is flawed, and only
| loosely correlated with cardiovascular health
| haldujai wrote:
| * * *
| jbandela1 wrote:
| Evidence Based Medicine is one of those things that is a good
| thing, but was pushed so hard by its proponents that it ended up
| overemphasizing a particular kind of study as the only real way
| to know things in medicine.
|
| Yes, absolutely, medicine should be evidence based. Yes, large
| randomized, double blind, placebo controlled studies provide a
| lot of information.
|
| However, there are limitations with these kinds of studies.
|
| First, it may not be ethical or practical to study some things in
| this manner. For example, antibiotics for bacterial pneumonia has
| not had a randomized, double blind, placebo controlled study.
|
| Famously, there was an article discussing how parachutes in
| jumping out of airplanes had not been subject to a randomized,
| double blind, placebo controlled study.
| https://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/
|
| Later, somebody did that study:
| https://www.bmj.com/content/363/bmj.k5094 and found that
| parachutes made no difference, but it is not applicable to any
| real world case where you would use a parachute.
|
| Which illustrates the second issue with evidence based medicine.
| Many times, the large trials's main thing they are measuring are
| different than what you really want to know, or the population
| they studied has significant differences from the patient who is
| right in front of you. How to apply the results of the large
| study to the individual patient in front of you is still more of
| an art than a science.
|
| Finally, I think there is the example from machine learning. It
| has turned out that instead of creating more and more rules,
| feeding lots and lots of data to a neural network ends up
| performing better in a lot of machine learning cases. In a
| similar way, an experienced physician who has treated thousands
| of patients over decades has a lot of implicit knowledge and
| patterns stored in their (human) neural networks. Yes, these
| decisions should be informed by the results of trials, but they
| should not be discounted, which I think that Evidence Based
| Medicine did in at least a small part. During my residency, I
| worked with physicians who would examine and talk with a patient
| and tell me that something is not right and to do more extensive
| tests which would end up unearthing a hidden infection or other
| problem that we were able to treat before it caused major
| problems. They were seeing subtle patterns from decades of
| experience that might not even be fully captured in the patient's
| chart, much less a clinical trial without thousands of
| participants.
|
| So yes, these clinical trials are a very important base for
| knowledge. But so is physician judgment and experience.
|
| Source: I am a physician.
| Gatsky wrote:
| The biggest issue, IMHO, is that clinical trials are often
| unethical. This is both in theory and especially in practice. I
| say this as a physician and clinical trial investigator.
|
| EBM deals with this by saying 'there is no viable alternative',
| a remarkable statement of epistemological nihilism that enables
| much low quality snd pointless research.
| nradov wrote:
| This is a central point in the new book _Outlive_ by Dr. Peter
| Attia. RCTs are great, but realistically we 're never going to
| have long-term RCTs that give clear evidence on prevention of
| the chronic diseases that will probably kill most of us. A long
| RCT might measure the effect of a certain intervention over
| like five years but we need to think in terms of _decades_. No
| one is willing to fund those studies, and even if funding wasn
| 't an issue the evidence would come too late for those of us
| alive today. So, we have to rely on weaker forms of evidence
| evaluated in a cost (or risk) versus benefit framework.
|
| https://peterattiamd.com/outlive/
| haldujai wrote:
| I think of EBM as "where stronger evidence exists it trumps
| expert opinion" (almost all of the time). In other words, go
| down the hierarchy[0].
|
| > I worked with physicians who would examine and talk with a
| patient and tell me that something is not right and to do more
| extensive tests which would end up unearthing a hidden
| infection or other problem that we were able to treat before it
| caused major problems.
|
| Accordingly I don't view this as discordant with an evidence
| based medicine practice as you're not practicing in an area
| with clinical-trial evidence (and notably, expert opinion _is_
| evidence albeit weak). If you told me you did routine
| urinalysis and blood cultures on all your admissions I would
| view that as discordant and incorrect practice, regardless if
| expert dinosaur feels it saves lives in their experience.
|
| I also view EBM as opposed to "science-based medicine". Just
| because something has a (theoretical) scientific basis it does
| not meet the standard to enter my routine practice, I need
| stronger evidence for that which notably does not have to be in
| the form of a RCT as you suggest[0].
|
| > How to apply the results of the large study to the individual
| patient in front of you is still more of an art than a science.
|
| Frankly, the practice of medicine is more art than science and
| EBM is a guiding principle that keeps us grounded to measurable
| outcomes.
|
| [0] https://en.wikipedia.org/wiki/Hierarchy_of_evidence
| jahanpd wrote:
| Best comment on the thread.
| user3939382 wrote:
| Good lecture on this topic https://youtu.be/z6IO2DZjOkY
| hospitalJail wrote:
| I'd love the idea of science based medicine. There are a few
| issues:
|
| >HIPPA has made it basically impossible to do science in Medicine
| without being part of the establishment
|
| >The medical cartels hate change, its bad for business, they
| actively lobby against change and competition. They want
| authority based medicine.
|
| >The scientist responsible for the discovery and treatment of an
| issue, can't even legally practice.
|
| We should entirely be blaming the medical cartels here. They have
| been terrible for our health, technology, and wallets.
| ethanbond wrote:
| What exactly is HIPAA's role here? With or without HIPAA,
| medical institutions don't want to share their data, especially
| not the ones with _good_ data because they do their own
| research.
| SkyPuncher wrote:
| As someone more familiar with HIPAA than the average lay
| person (but far from an expert).
|
| There's a lot that HIPAA does to both restrict access to data
| and ensure that's it's shared freely among institutions. It's
| kind of this weird open-secret system that works because
| people get fired for even minor offense.
|
| I don't know what life was like before HIPAA, but after HIPAA
| it creates a lot of risk aversion. These seems to come out in
| two ways:
|
| * Risk of identifiable information leaking via a published
| report. Anonymizing data is much harder than most people
| anticipate.
|
| * Internal auditing and appropriate use. "Opening" a
| patient's record has to either be (1) for their care (2) an
| explicitly permitted use from the patient (research). That
| means while an institution must be a steward of their
| patient's data, they cannot simply use it however they want.
| This isn't much different AWS's handling of customer
| databases. While AWS keeps all of the data on their servers,
| they don't really have access to it.
| jvanderbot wrote:
| not op: but possibly ... The free exchange of information
| would make publicly funded data-driven discoveries more
| feasible. (?)
| ethanbond wrote:
| HIPAA is not the impediment, incentives are.
| SkyPuncher wrote:
| That's what standards like FIHR and HL7 do. While
| interchange is a problem, permissible use is a
| significantly higher bar.
| chimeracoder wrote:
| > What exactly is HIPAA's role here? With or without HIPAA,
| medical institutions don't want to share their data,
| especially not the ones with good data because they do their
| own research.
|
| I agree that OP's thesis doesn't make much sense.
|
| HIPAA provides a legal framework for institutions to share
| data without liability[0]. It doesn't apply at all to
| non-"institutional" actors (in the way that OP seems to be
| using the word "institutional").
|
| HIPAA is an extra cost for the big players, but there's
| little, if anything, that it prevents them from doing which
| they would otherwise want to do.
|
| [0] More precisely, it provides a framework for capping
| liability exposure for institutions
| spondylosaurus wrote:
| As a rule of thumb, I find it's usually safe to dismiss
| criticism of HIPAA from anyone who misspells it as HIPPA.
| Not knowing that it's an acronym for Health Insurance
| Portability and Accountability Act (emphasis on
| _portability_ there, as you pointed out!) tends to be a
| sign that you don 't know what the hell HIPAA is or is for.
|
| "HIPPA," on the other hand, is an ever-convenient boogeyman
| you can invoke in all kinds of situations.
| SkyPuncher wrote:
| Being pedantic. Calling people out on HIPAA/HIPPA is like
| the warn out slight-of-hand trick you pull at a party and
| everyone pretends to laugh.
|
| I've never seen anyone who actually understands HIPAA get
| caught up on this. It's a common typo/misspelling.
| spondylosaurus wrote:
| You'd think it's a common typo, but I have literally only
| ever seen it spelled as "HIPPA" by people trying to use
| HIPAA as a punching bag for whatever happens to be their
| current pet issue. And those people almost _always_
| misspell it.
|
| The number of anti-vaxxers citing "HIPPA" as the reason
| why the local concert hall was trampling on their civil
| rights by asking to see proof of vaccination was...
| extremely high.
| chimeracoder wrote:
| > >HIPPA has made it basically impossible to do science in
| Medicine without being part of the establishment
|
| I really don't follow this line of reasoning at all.
|
| If anything, HIPAA makes it really hard _for_ "the
| establishment" to do medicine. It actually doesn't apply to
| non-"establishment" actors at all, because they're largely
| independent entities that are not subject to HIPAA by law.
| Fomite wrote:
| "HIPPA has made it basically impossible to do science in
| Medicine without being part of the establishment"
|
| I was able to get access to, and use, HIPPA data as a graduate
| student working in a field most of the "establishment"
| dismisses as either useless or confusing.
|
| "The scientist responsible for the discovery and treatment of
| an issue, can't even legally practice."
|
| I work with a half-dozen practicing physician-scientists.
| janeway wrote:
| I am sure I miss the context but I guess the point is that
| authors were sick of hearing about the promise of statistical
| analysis and epidemiology which will outperform classical medical
| approach - slandering the BMJ several times for some reason.
|
| Even today we see some hanger-ons who assert that their way is
| the best way - that they know from personal medical cases and
| their opinion and interpretation is more valuable than some
| statistical prediction.
|
| Well, if I have understood their sentiment correctly; facts are
| facts. Today the best medical care in the world is driven by
| data-based adaption rather than subjective opinion. If a
| treatment has a robust statistical impact it will be preferred.
| If new methods produce outcomes no better than random noise then
| we must agree that they are not better. If the physician has
| anecdotes about why they think some trick works best then - in
| the words of Pearson - "statistics on the table, please".
|
| I am sorry to make the joke but it seems apt: "Dr Charlatan
| disgruntled about needing evidence for science".
| Retric wrote:
| Yes and no,
|
| Statistics have an inherent weakness when you don't have
| consistent buckets to place everything into. If individual
| specialists classify cases differently they really can see
| statistically valid numbers from relatively few cases where
| double blind studies using different classification criteria
| see improvements below the noise floor.
| mjburgess wrote:
| Also, largely, there is no scientific evidence for the vast
| majority of problems.
|
| The only evidential basis for causal analysis are experiments
| where (1) you intervene to bring about the cause
| deterministically; and (2) where you control all confounding
| causes.
|
| Those conditions are impossible to meet for the vast majority
| of interactions in complex systems, such as people &
| medicine.
|
| If you run associative statistics on counfounded data
| collected in observational studies, you may as well correlate
| star signs with outcomes -- no doubt people being treated
| under winter signs will do worse than those under gemini.
| Astrology QED.
| LorenPechtel wrote:
| Brings to mind an interesting tidbit I ran into--long ago
| your sign probably did correlate with meaningful things in
| life. Not that the stars mattered, but the seasons did.
| Early life nutrition would vary. Even today you'll find a
| correlation between signs and ADHD diagnoses--because of
| the school year. There is almost a year of difference
| between the oldest students entering school and the
| youngest--and those youngest are appreciably more likely to
| get an ADHD diagnosis.
| bedobi wrote:
| as someone currently suffering from something I statistically
| have no real justification for getting fixed, I'm grateful I
| have a Dr who's going to fix it statistics be damned
| dekhn wrote:
| but if you got better, how would you know it was the doctor
| and not just random chance? base rate fallacy applies
| throwaway744678 wrote:
| At a personal level, why would one care? Their medical
| issue went away!
| bedobi wrote:
| In my case, I've been suffering from disc herniation
| induced sciatica for 5 months
|
| When I say suffering, I mean it - I haven't been able to
| stand, sit, lie down, walk, do anything without constant
| and extreme pain. For months on end now.
|
| There is a gold standard study called SPORT that proves
| more or less beyond all doubt that, in the long run, there
| is no difference in outcomes for patients who get disc
| herniations surgically removed vs those who don't. Disc
| herniations eventually heal themselves, all surgery does is
| fix them sooner than they otherwise would have.
|
| So the tax-funded public health care system in Sweden and
| other similar countries do not surgically remove disc
| herniations other than in extreme cases. (loss of bowel
| control etc)
|
| Thankfully, in the States, I'm able to have the surgery, so
| I will.
|
| I couldn't care less if in the long run there is no
| difference in the aggreggate - I don't want to wait another
| year or two or more for the herniation to heal itself.
|
| I'm not a statistic, I'm a human being lol.
| neverrroot wrote:
| [flagged]
| metalliqaz wrote:
| What are you talking about? The emergency procedures were used
| to get the new vaccines out quickly, but they have since
| completed the 'normal' procedures for approval.
| dang wrote:
| Regardless of what the GP said, you broke the site guidelines
| here, which ask you to edit out swipes (like "What are you
| talking about"). Your comment would be just fine without that
| bit.
|
| We've to ask you this kind of thing more than once before. If
| you wouldn't mind reviewing
| https://news.ycombinator.com/newsguidelines.html and taking
| the intended spirit of the site more to heart, we'd be
| grateful.
| satellite2 wrote:
| https://en.wikipedia.org/wiki/Bruce_Charlton
| pella wrote:
| (2020) Will COVID-19 be evidence-based medicine's nemesis?
|
| https://journals.plos.org/plosmedicine/article?id=10.1371/jo...
|
| _" It is surely time to turn to a more fit-for-purpose
| scientific paradigm. Complex adaptive systems theory proposes
| that precise quantification of particular cause-effect
| relationships is both impossible (because such relationships are
| not constant and cannot be meaningfully isolated) and unnecessary
| (because what matters is what emerges in a particular real-world
| situation). This paradigm proposes that where multiple factors
| are interacting in dynamic and unpredictable ways, naturalistic
| methods and rapid-cycle evaluation are the preferred study
| design. The 20th-century logic of evidence-based medicine, in
| which scientists pursued the goals of certainty, predictability
| and linear causality, remains useful in some circumstances (for
| example, the drug and vaccine trials referred to above). But at a
| population and system level, we need to embrace 21st-century
| epistemology and methods to study how best to cope with
| uncertainty, unpredictability and non-linear causality [16].
|
| In a complex system, the question driving scientific inquiry is
| not "what is the effect size and is it statistically significant
| once other variables have been controlled for?" but "does this
| intervention contribute, along with other factors, to a desirable
| outcome?". Multiple interventions might each contribute to an
| overall beneficial effect through heterogeneous effects on
| disparate causal pathways, even though none would have a
| statistically significant impact on any predefined variable [11].
| To illuminate such influences, we need to apply research designs
| that foreground dynamic interactions and emergence. These include
| in-depth, mixed-method case studies (primary research) and
| narrative reviews (secondary research) that tease out
| interconnections and highlight generative causality across the
| system [16, 17]."_
|
| table1:
| https://journals.plos.org/plosmedicine/article?id=10.1371/jo...
| kspacewalk2 wrote:
| Sounds extremely susceptible to quackery and hand-waving
| appeals to authority.
| [deleted]
| cactusplant7374 wrote:
| I thought all medicine is evidence based as long as it's not
| homeopathic or chiropractic?
| bedobi wrote:
| homeopathic medicine, chiropractic medicine, folk medicine,
| traditional medicine, osteopathic medicine, crystal healing
| medicine... you can make an infinite list of nonsense
|
| and if you want to disambiguate and say "evidence based
| medicine" to refer to actual medicine, they can just make it
| "evidence based homeopathic medicine" and so on and so on
|
| can't beat these people
| [deleted]
| msla wrote:
| > they can just make it "evidence based homeopathic medicine"
| and so on and so on
|
| Only if the homeopaths lie about the evidence.
| smegsicle wrote:
| curious how combative some people seem to get about
| homeopathics when placebo has been shown to have consistent
| positive effect, without side effects, for almost every
| illness
| metalliqaz wrote:
| they aren't honestly trying to sell placebos (like
| Zeebo). They are marketing actual 'cures' for serious
| maladies that could respond to real treatments
| technothrasher wrote:
| If placebos don't have side effects, why do the control
| groups in placebo-based trials always report side
| effects?
|
| And given that "homeopathic" to most casually informed
| people is the same as "naturopathic", what those people
| are taking are not necessarily harmless placebos.
|
| As for your "almost every illness," that's just
| meaningless hyperbole.
| mistrial9 wrote:
| when Western doctors visited China under Nixon, the great
| medical practices of Chinese medicine were on full view ..
| acupuncture, herbs, other parts.. The Western Doctors
| uniformly mocked the Chinese upon return.. oddly reminiscent
| of the Chinese mocking the "stone age" Tibetans at a later
| date. zero medicine anywhere but in your own guild, it seems
| pella wrote:
| _" (effect sizes) Some of our favorite medications, including
| statins, anticholinergics, and bisphosphonates, don't reach the
| 0.50 level. And many more, including triptans, benzodiazepines
| (!), and Ritalin (!!) don't reach 0.875."_
|
| _" There's no anti-ibuprofen lobby trying to rile people up
| about NSAIDs, so nobody's pointed out that this is "clinically
| insignificant". But by traditional standards, it is!"_
|
| read more: All Medications Are Insignificant In The Eyes Of God
| And Traditional Effect Size Criteria ( MAY 31, 2023 )
| https://astralcodexten.substack.com/p/all-medications-are-in...
| Vecr wrote:
| Not really, people probably have better examples but doctors
| quite often don't actually try to figure out what antibiotic is
| the best, they just pick something for no real reason (they
| remember the name) and write a prescription. There are studies
| on what antibiotic to use quite a lot of the time, but that
| takes effort. You get a Z-Pack, and you get a Z-Pack, etc...
| dekhn wrote:
| Probably one of the best known examples is the establishment
| as helicobacter pylori as the ultimate cause of ulcers,
| rather than stress, spicy food, and low pH. Marshall won the
| nobel prize for this, and it's often touted as a situation
| where there was a lot of initial non-scientific resistence
| "of course we know it's stress..."
| hvs wrote:
| https://pubmed.ncbi.nlm.nih.gov/9276585/ I
| conclude that attempts to classify medical decisions as
| justified or unjustified by scientific evidence have no
| foundation in logic and that the term 'evidence-based
| medicine' is logically indistinguishable from the term
| 'medicine'. The use of the term 'evidence-based medicine'
| calls for a new type of authoritarianism in medical practice.
| Dma54rhs wrote:
| It's often based on authority and tradition, evidence based is
| a fairly new idea.
| 5040 wrote:
| The ancient medical schools varied quite a bit when it came to
| questions of evidence. Something to think about perhaps.
|
| > _The Empiricists were sceptics in their attitude to causes,
| thinking that observation and report of evident conditions and
| their cures was sufficient for medical science, and thus
| eschewing causal theory. Rationalist doctors attacked the
| inadequate methodology of the Empiricists, and they try to
| explain why the antecedent cause should bring on such and such
| an effect, while emphasizing the need to decide rationally the
| proper use of induction, and the relevancy of similarities. The
| Methodists treat as irrelevant antecedent causes or factors,
| and they recognized just two pathological conditions--
| relaxation and constriction; the doctor 's concern is to
| determine by direct observation in which state is the body._
| bjornsing wrote:
| The main flaw in EBM is that it inverts the scientific method:
| It's no longer about hypotheses and falsification. Instead it's
| about "scientifically proven facts" (aka "evidence"). Sadly this
| aligns much better with our dogmatic instinctive understanding of
| knowledge as a set of agreed truths.
| haldujai wrote:
| It's because medicine is as much an art as a science given the
| impossibility of problem space, also whenever we ignore
| evidence we end up harming/killing people.
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