15 March 2016

Evidence based medicine: how passe is it really? A layman micro-fascist's view.

‘There are in fact, two things, science and opinion;
the former begets knowledge, the latter ignorance.’

Anyone who doesn't look at modern medicine with sense of wonder, liberally mixed with trepidation, could skip this post altogether. However, the goings-on in some corners of this noble activity area should be of interest to many, I would suggest. Since you never know...

The whole story started with a Facebook friend posting a link to an article with an intriguing title:

Deconstructing the evidence-based discourse in health sciences: truth, power and fascism

Here is the full abstract of the article:
Background Drawing on the work of the late French philosophers Deleuze and
Guattari, the objective of this paper is to demonstrate that the evidence-based movement in the health sciences is outrageously exclusionary and dangerously normative with regards to scientific knowledge. As such, we assert that the evidence-based movement in health sciences constitutes a good example of microfascism at play in the contemporary scientific arena.
Objective The philosophical work of Deleuze and Guattari proves to be useful in showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm – that of post-positivism – but also and foremost in showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure.
Conclusion The Cochrane Group, among others, has created a hierarchy that has been endorsed by many academic institutions, and that serves to (re)produce the exclusion of certain forms of research. Because ‘regimes of truth’ such as the evidence-based movement currently enjoy a privileged status, scholars have not only a scientific duty, but also an ethical obligation to deconstruct these regimes of power.
Of course, fascist takeover of the medical practice, so close to my heart (in all senses, my heart being an object of some medical practice for a few years already) doesn't bode well for anyone treated by the said practice. So I read the whole article, while intermittently breaking out in hot or cold sweat, depending on the passage.

The antifascist and anti-colonial thrust of the piece is not tempered much by the authors' attempt to soften the "fascist" part:
Although it is associated with specific political systems, this fascism of the masses, as was practised by Hitler and Mussolini, has today been replaced by a system of microfascisms – polymorphous intolerances that are revealed in more subtle ways.
Not much tempered, as I said, because there is an immediate addendum:
Consequently, although the majority of the current manifestations of fascism are less brutal, they are nevertheless more pernicious.
Just to make sure the reader knows what is that fascist colonial overprivileged phenomenon that Dave Holmes RN PhD and other authors of this article fight:
As a global term, EBHS (evidence-based health sciences) reflects clinical practice based on scientific inquiry.
And why should practice based on scientific inquiry be a suspect? Because:
When only one method of knowledge production is promoted and validated, the implication is that health sciences are gradually reduced to EBHS. Indeed, the legitimacy of health sciences knowledge that is not based on specific research designs comes to be questioned, if not dismissed altogether.
What is that health sciences knowledge that is encroached upon and endangered by EBHS? It was the question that I've tried to get answered most of the time while going through Google. The article in question doesn't provide an answer, offering only attacks of the following kind:
Those who are wedded to the idea of ‘evidence’ in the health sciences maintain what is essentially a Newtonian, mechanistic world view: they tend to believe that reality is objective, which is to say that it exists, ‘out there’, absolutely independent of the human observer, and of the observer’s intentions and observations. They fondly point to ‘facts’, while they are forced to dismiss ‘values’ as somehow unscientific. For them, this reality (an ensemble of facts) corresponds to an objectively real and mechanical world. But this form of empiricism, we would argue, fetishises the object at the expense of the human subject, for whom this world has a vital significance and meaning in the first place. An evidence-based, empirical world view is dangerously reductive insofar as it negates the personal and interpersonal significance and meaning of a world that is first and foremost a relational world, and not a fixed set of objects, partes extra partes.
You shall find a plethora of philosophical discourse, references to Derrida, Deleuze, Guattari, Hanna Arendt (!) and even Orwell (in a more heated passage of the article that again bashes fascism as a precursor of EBHS). But not a shadow of reference to EBM/EBHS alternatives.

Well, a sensible reader might dismiss the article as a spoof or a curio, to serve as an example of unmatched ridiculousness and simply laugh it off. Unfortunately, it is not a spoof and, even more unfortunately, the authors of that article are not alone in the medical universe. There are many other bashers of EBM/EBHS or any other acronym that starts with E(vidence) Based whatever. Apparently, attempts to put various branches of medicine on scientific feet are not to the taste of a quite large group of people.

And then, of course, I have searched for "alternatives to evidence based medicine". The highest rated and most frequently referred to article on the subject, Seven alternatives to evidence based medicine, is a hilarious takedown of the post-modernists (post-medicine?) opponents of EBM. A must read. To give you a taster of the article, here is the first of the alternatives on offer:
Eminence based medicine — The more senior the colleague, the less importance he or she placed on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as “making the same mistakes with increasing confidence over an impressive number of years.” The eminent physician's white hair and balding pate are called the “halo” effect.
Is this the kind of an alternative to EBM the authors of that incendiary piece have in mind? I don't really know. But I had a problem with finding a serious answer to the question of alternatives. A glimpse into the mindset of some objectors to EBM appears here:
Proponents of EBM have argued that complementary and alternative medicine (CAM) modalities ought to be subjected to rigorous, controlled clinical trials in order to assess their efficacy. However, this does not represent a scientific necessity, but rather is a philosophical demand: promoters of EBM seek to establish their particular epistemology as the primary arbiter of all medical knowledge. This claim is problematic. The methods for obtaining knowledge in a healing art must be coherent with that art's underlying understanding and theory of illness.
So - "healing art" - this is what it comes down to? Really? I don't even want to go into the discussion of so called CAM, which harbors a fare share of quacks and charlatans... but here is a nice reply to the "artists".

Eventually I hit gold. No, I wasn't able to find a serious article that would show a viable alternative to EBM, unfortunately. But I have found someone who put things in order for me, as a real scientist ought to: Stephen D. Simon aka P.Mean (Professor Mean), whose article The post-modern assault on evidence-based medicine has done a lot for my layman's basic understanding of the main terms and of the whole battle around the discipline I was used to regard as more or less scientific (more about Steve Simon here and here). To start with - a good definition of EBP* (Evidence Base Practice)**:
"the integration of best research evidence with clinical expertise and patient values." (Sackett 2000)
As you can see, patient values are not ignored by EBP, no matter what that other crowd claims. As for the main steps in fulfilling the EBP process:
The five steps in applying EBP in a clinical situation are:
  • CONVERT the need for information into answerable questions.
  • TRACK DOWN the best evidence with which to answer the questions.
  • CRITICALLY APPRAISE the evidence for its validity, impact, and applicability.
  • INTEGRATE the critical appraisal with our clinical expertise and with our patient's unique biology, values, and circumstances.
  • EVALUATE our effectiveness and efficiency in executing steps 1-4 and seek ways to improve them both for next time.
Far from being unreasonable or incomplete, you must agree. And another important clarification, to place EBP in the historical perspective:
What was life like before EBP? It is very important to place EBP in context by noting what it has replaced. Before EBP became prominent, changes in medicine occurred when a small group of respected experts opined that changes were needed. This is practice is labeled eminence-based medicine.[see the definition above]
And here (finally) a first glimpse of an answer to the question that so bothered me. Well, a glimpse only and not very satisfactory:
What do post-modern critics want to replace EBP with? Holmes (2004) uses the analogy of the rhizome. A ginger bulb is an example of a rhizome. The rhizome is a good analogy for post-modern nursing because

"the rhizome is open at both ends. It has no central or governing structure; it has neither beginning nor end. As a rhizome has no centre, it spreads continuously without beginning or ending and basically exists in a constant state of play. It does not conform to a unidirectional or linear reasoning. The rhizome challenges the sense of a unique direction because it emerges and grows in simultaneous, multiple ways." (Holmes 2004)
It sounds both philosophical and poetic, wouldn't you agree? But if I (for instance), suffer from an ulcerative colitis, I would prefer my physician to offer me a path of treatment that is less open-ended and multi-directional. More substance and more proof of validity, based on... what the heck - on solid evidence, please, I would say. And as for rhizome: never mind, leave it in your office, please, for study during your off-shift time, dear prof Holmes. Or, simply put, stick it...

Well, do read that P.Mean's article in full - it is very educational and well written. As for fascism and the founder of EBM/EBP, here is a hilarious rebuff of that stupid attempt at an analogy:
"But Archie Cochrane, on the other hand, pioneering epidemiologist, inspiration for the Cochrane Library, a prisoner of war for four years in Nazi Germany, who has, from his abstracted position, probably saved more lives than any doctor you know, might see it differently, since in 1936, he went to Spain to join the International Brigade, and fight the fascists of General Franco. Now, what did you do with your summer holidays?" (Goldacre 2006)
At ease, prof Holmes!

(*) As for the proliferation of acronyms, for starters here comes a clarification:
What is evidence based practice? Evidence Based Practice has radically changed our health care system. This is an umbrella term for Evidence Based Medicine, Evidence Based Nursing, Evidence Based Dentistry, Evidence Based Mental Health, and so forth. The term Evidence Based Practice is preferred by many because it incorporates the interests of all health care professionals.
(**) Not to say that the adherents of evidence based medicine don't have their differences of opinion, like here. But it is rather in good spirit and not destructive like the onslaught of the goons that started this post.