Wednesday, October 24, 2012

EBM

I have to get this off my chest.
It's been bothering me somewhat for the last couple of weeks.
If you've been following that thread on Facebook, you probably know what's been going on. I belong to a FB group, name of which I won't divulge, that consists of Malaysian doctors. Primary care and specialists. Things started when another doctor asked me for my opinion as an endocrinologist about the numerous supplements he was taking. L-thyroxine, some compounded testosterone and adrenal androgens, as well as a host of other supplements. He called it his 'cocktail'. And so I shared that I personally wouldn't recommend it as the evidence out there does not suggest it should be done.
And this started a heated online debate about the topic of evidence-based medicine, not only related to endocrinology but medicine as a whole. While I fully acknowledge that individuals are for sure going to have different opinions and I respect that, what I wasn't prepared to see was the number of comments from people who were totally condemning the concept of EBM.
And perhaps this was a greater surprise to me because one of the integral foundations to my training at my alma mater is that we've been drilled to always question the data. To critically appraise a study and read between the lines; to not just accept the authors' conclusions but to find flaws and to make our own decisions about its validity. As residents, we regularly attended Journal Club conferences and presented at quite a few. When we suggested something, our attendings would often challenge us: "Cite your references..."
In fact in some of my papers you'd see me actually spelling out what the limitations of my studies were; not just presenting the strong points.
It's a principle I hold closely and I apply it to tests I might order, or medications I may prescribe.
"Prove to me that your medication results in better outcomes for my patient"
"Prove to me that your medication is safe"
It's something I've assumed the scientist in all physicians would question.
And so, it was surprising to see such a shift in thinking, to see my peers, just dismiss EBM as some voodoo. Or that EBM is flawed because it is manipulated by pharma. That "EBM is the worse form of science". Or that EBM is not reliable because no one studies natural supplements that are not patented because of the lack of profit.
The criticisms of the concept of Evidence-Based Medicine was staggering, and almost seemed to be bordering on ignorance or paranoia. And while they were dissing this, many seemed very open to recommending unconventional or alternative treatments. Quoting not textbooks or medical journals, but websites or books on spirituality, with generous statements like all lung cancer was due to "one of 30 mutations", or "this works because I felt better on it" and "where can I get some?"
The truth is, EBM is flawed. Yes, it's not a perfect science. And it can be intimidating- though I've published some papers and have done some research, I still consider myself a greenhorn and get overwhelmed sometimes (and I recall actually hating EBM as a medstudent). And science itself does not tell us everything. True, studies might be biased by monetary or nonmonetary factors. And the lack of evidence regarding efficacy of a treatment is not the same as the presence of evidence showing harm. But that's precisely it. The concept of EBM is not to say we should believe the publications out there. That all scientific studies are reliable. Far from it- the basis of evidence-based medicine is that it is meant to make us question the data. To force us to use our analytical brain and to make our own decisions on whether or not to believe the manuscript we are reading. To determine if a study was well-designed and free of bias. If the results are valid.
I realize that professional opinions differ, not only interregionally but even here. But I have to admit, I'm somewhat disturbed by the noise that was generated. I can't help to wonder, if doctors were not making treatment decisions based on the science, then what else is there to guide us?


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