Evidence based medicine
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.842 (Published 01 April 2004) Cite this as: BMJ 2004;328:842All rapid responses
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Evidence-Based Medicine and Innovation
Loefler1 recently expressed concerns that Evidence- Based Medicine (EBM)
might stifle innovation.
This seems to assume that EBM enthusiasts feel that one should only
base practice on existing knowledge and that the quest for improved
treatments should be abandoned. Surely, this is not the case.
Firstly, one of the benefits of EBM is that it identifies where
evidence/ research is lacking. Secondly, EBM provides a framework to
ensure that any research addressing the gaps in our knowledge is conducted
in a thorough and rigorous fashion.
Therefore, it seems reasonable to assert that EBM not only
facilitates innovation but ensures that innovative work is performed in an
unbiased manner eschewing maverick practice.
1. Loefler I. Soundings. Evidence based medicine. BMJ 2004; 328: 842.
MacDara McCauley
Senior Registrar,
Department of Psychiatry,
Our Lady’s Hospital Navan,
Ireland
Competing interests:
None declared
Competing interests: No competing interests
This is not the Willam Withering I remember being taught about. By
chance, Dr John Davis wrote in the letters section of the Daily Telegraph
today another version of the truth:
Dear Sir — The foxglove (Digitalis purpurea),found in “Birmingham’s
parks, industrial wastelands and ‘endless village’” is appropriately
chosen as the city’s emblem (reported in the Daily Telegraph, May 5), but
a more important reason would be to celebrate the life and work of William
Withering. He lived in Edgbaston Hall and discovered the clinical use of
digitalis in the treatment of heart disease. His 1785 monograph, An
Account of the Foxglove and some of its Medical Uses with Practical
Remarks on Dropsy and other Diseases, still stands as a model of
scientific writing, and earned him a Fellowship of the Royal Society. He
died in 1799 and his memorial in Edgbaston old church shows a flowering
foxglove and interestingly also, a branch of Witheringia — a tropical
genus named for him to mark his eminence as a botanist. But his real
memorial is the foxglove, of which there are quantities in front of the
medical school at Birmingham — a beautiful sight in summer and a
commemoration of this great Birmingham physician. Dr John Davis Birmingham
Conflicts of interest. Dr Davis taught pharmacology and physiology to
a generation of anaesthetists at Birmingham Children's Hospital of which I
was one. Edgbaston Hall is now a school.
Competing interests:
See script
Competing interests: No competing interests
Dear Sir,
Regarding evidence based medicine, there is one story which might
illustrate the vagaries of EBM, and that is the story of digitalis.
I can give you no references, since I read about this in the Philson
medical library, while whiling away some time. It was of no direct
interest to me, except insofar as it was interesting. So I took some
notes. No doubt, those with relevant historical medical texts will
confirm the validity of these interesting asides.
What is most interesting about digitalis, is that even with modern
technology today, the nature of digitalis cannot be explained
satisfactorily.
What next caught my eye was that in the late 1770's, when William
Withering was experimenting with it, he used such high doses, so often,
that in the opinion of his colleagues, his patients were surely in mortal
danger. Were he reinacting these experiments today, I'm sure his
experiments would be disallowed as being highly unethical...
But the really interesting thing was how he came upon digitalis. He
is often quoted as the "discoverer" of digitalis, but that is not true.
It came to his attention in 1775, when an old woman in Shropshire, England
had gained widespread fame from a herbal mix, by curing dropsy, where his
colleagues failed. He studied this mixture extensively, and came to the
conclusion that what she called "foxglove" was an substance worth a lot
more investigation.
The reality is that modern medicine wouldn't have digitalis today,
were it solely down to EBM standards of today.
We have digitalis, from foxglove, because a visionary man listened to
an old woman and believed her. And the evidence of his eyes, that she
suceeded, where he and his colleagues failed. Neither would we have
digitalis today, if someone more "normal" than William Withering (who
didn't give a toss what others thought), had listened to his wet-
blanketted colleagues.
But within the whole EBM debate, lies something that Imre Loefler
neglects to mention.
The real issue here is perhaps one of hypocrisy. The medical
profession has a habit of routinely decrying anything it cannot explain,
or considers is quackery.
13 years ago, your journal published an article which said this (1):
***only about 15% of medical interventions are supported by solid
scientific evidence, David Eddy, Professor of Health Policy and Management
at Duke University, North Carolina, told a conference in Manchester last
week. This is partly because only 1% of the articles in medical journals
are scientifically sound and partly because many treatments have never
been assessed at all.
“If,” said Professor Eddy “it is true, as the total quality
management gurus tell us, that ‘every defect is a treasure’ then we are
sitting on King Solomon’s mine.” ****
Elsewhere in the E letters, I have posted evidence that this
situation exists to this day.
The medical profession is finally prepared to admit that much of the
time, they are flying by the seat of their pants, the whim of an
observation, and a hope, if not a prayer.
Extending that logic, it would be helpful then if they might think a
little harder before telling patients that traditional medicine
modalities, including such things as acupuncture, homeopathy, herbalism
etc, aren't proven to work, on the basis of a lack of evidence based
medicine.
The fact is that a far larger percentage of cultures in the world,
are proving every day, that traditional medicine modalities work as well
today, as they did in 1775.
Something William Withering, for all the lack of EBM in those days,
was prepared to learn from.
Hilary Butler.
1) BMJ Vol. 303, 5 October 1991 The poverty of medical evidence”
Competing interests:
None declared
Competing interests: No competing interests
Evidence based medicine. Another comment by Mr.Loefler that is
written in such enviable English that only Peter Morrell could match.
But Mr. Loefler fades a bit toward the end and he does not make a
convincing case for EBM in any way.
'Evidence based medicine' was present when Ancell Keys in Minnesota
decided that the presence of cholesterol in the arteries of the deceased
meant that cholesterol was the cause of the subjects' demise. That's like
saying the firemen you meet at every major fire caused the fire because
they seem to be present at all fires! And what evidence is there in favour
of the cholesterol hypothesis?!
Dr. Denis Burkett would have linked evidence based medicine with the size
of the stools he discovered at the roadsides of Uganda.
"You match this and you will outlive your doctor!"
To me, EBM is another one of those fancy, high-fallutin' inventions like
the glycaemic index (GI), a pretty unscientific and useless gadget that is
nevertheless very popular.
EBM is truly loved by most practitioners, including all quacks. "Five
drops of this diluted goat pterygium cured Mrs. Jones' obesity".
Evidence is, I believe, another marketing tool.
Could we just go back to being concerned for our neighbours and friends
and help if we can ?
Or have we really lost it?
Competing interests:
None declared
Competing interests: No competing interests
Sir
Once again Imre Loefler has hit the nail squarely on the head. I
hope that his occasional submissions will be collected and published as
required reading for all medical practitioners, students and graduates
alike.
Yours,
Richard Newell
Competing interests:
None declared
Competing interests: No competing interests
"Need for Evidence" or "Evidence for Need"?
Dear Sir,
I read with the greatest interest the article by I. Loefler. I would
be honored to add another point of view to this interesting discussion.
Throughout their histories, science and medicine have always been
"brothers in arms". Unfortunately, the first was promoting inductive
reasoning, the latter a deductive approach. For about twenty years, EBM
has offered the bridge, and to reconcile, these two complementary aspects
of human knowledge.
However, we have to acknowledge that the actual hype on EBM may lead
to abuse. The good well-known old "Aunt Minnie" may sometimes be wrongly
disregarded towards "Uncle Sam", who actually has the EBM label. Look at
the redundant publication of meta-analyses on the same topic, sometimes
leading to conflicting results. After so many efforts put together to
raise reason as the promoter of medical science, has EBM turned to a
victim of its success?
The medical evidence pool requires to be irrigated upstream and to
flow downstream. Downstream by meta-analysis and EBM guidelines, upstream
by high quality, meaningful basic data. The time has come for EBM to
provide the medical research guidelines not only for clinical trials, but
also for the development, assessment and validation of screening methods,
prognostic tests, adverse effects, etc. Its aims should not only be to
tell where and how to draw reliable evidence, but to help developing
reliable data in certain fields of research that will ultimately be used
as support for evidence. Otherwise, the benefits of clear and usable EBM
might be shadowed by the growing controversy on how to assess the evidence
provided by evidence-based medicine. The need for evidence must be
balanced by the evidence for need.
Competing interests:
None declared
Competing interests: No competing interests