My wife and I were just talking about this yesterday. She is an extremely specialized surgeon and she is horrified by the academic publishing in her area of expertise. It is often utterly wrong and conflicts directly with her experience. I'm not sure she'd agree with the reasons mentioned in this article here as the main issue - although we have personally seen less ethically motivated doctors publishing research to help line their pockets via the industry. In her opinion the main issue is that academic doctors HAVE to publish in order to advance their careers. So you end up with a never ending stream of terrible research, churned out by doctors that are not experts in doing research and that actually spend most of their time doing other things. This happens even at the best centers; at least in her area of expertise. I don't know what the solution is, but I do know that whenever she has needed treatment for herself she generally ignores most of the research and talks to the most experienced surgeon she can find.
Evidence-based medicine, more than the indeed important issues raised in the article, is mostly impaired by the absolutely abysmal average quality of clinical research papers. The absolutism of higher-ups combined with their unrivalled (in the scientific world) statistical ignorance is hurting science more than anything else. And there's a reason to that: MDs are not scientists. We're highly-skilled workers, and more of the blue-collar kind.
After reading this article I find only one problem with it, and that is the title.<p>The problem the authors have so perfectly characterized has nothing to do with the emphasis on evidence that medicine requires, but on the distortion imposed on the system by large pharmaceutical companies.<p>The reality of the obstacles standing in the way of rigorous testing for drug or therapy effectiveness does not make evidence-based medicine an illusion.<p>In fact, the authors actually make a strong argument in favor of evidence-based medicine, by stating the need to acknowledge these biases. And that the reason for all these biases is greed.
One thing that has always stuck with me in regards to this topic is the lack of medical research in areas that need it but don’t get it because there isn’t any money in it. One area that comes to mind is feline urinary tract disease. Many years ago, I had a cat who kept coming down with this, and the vet(s) were at a total loss as to how this kept happening. So I decided to open up the literature and plough into it as a layman with no knowledge about animal medicine. Within the space of a single hour I quickly learned that many of the most common diseases facing animals have very little research behind them and a lot of unknowns. Which brings me back to one of the main points of the author. If the neoliberal approach to research is only going to focus on what is profitable to treat, then medical science as a whole has backed itself into a dark corner.
As someone who recently complained to the UK Royal College of Veterinary Surgeons and got palmed off because the UK legislation doesnt quantify "reasonable care", the whole system is one giant authoritarian money making scam.<p>I dont know what professionals are being taught in med/vet/law school now a days, but technology is increasingly demonstrating that professionals could be out of date by the end of their course!<p>So that problem of trying to stay current in IT is spreading out into other professions and I dont see them tackling this problem like the IT sector has/does.
Medical industry is corruption prone.<p>Another example: Industry sponsored conferences. Doctors are invited to a 3 day 4 star hotel stay to attend a conference. Technically, talks that are paid shilling are specially marked as sponsored talks.<p>But are the other doctors, who are getting paid to speak there 100% independent?<p>Will you be a 100% independent doctor after getting free presents?<p>Maybe you will. But industry probably found its profitable if they spent millions on these kinds of conferences.<p>Also lie repeated multiple times makes you believe in, there are psychological studies. So when you spend hour listening how drug X is gold, you might start believing its gold
Drug company bias is definitely a well known issue. But there are even bigger issues with science based medicine.<p>* MDs are not PhDs for one, though people often equate the two.<p>* Things like surgery is in fact hard to test. There are ethical issues around it. E.g. are you really going to do a shame surgery "for science" if you think there is a chance it might save the patients life? On the flip side, surgery has a lot of risk, and performing surgery that doesn't work exposes patients to unnecessary risk.<p>* There are entire fields where pseudo-science is common. Notably a lot of physical therapy and chiropracty is not science based.
Over the years I've practiced medicine the idea of "evidence-based" care has had its ups and downs.<p>Part of the problem lies in the question of what is "evidence". From what I've seen, heard and read, the question is broader than pharmaceutical research though that's certainly an important element. The evidence literature spans making diagnoses, applying drug and non-drug therapies, deciding what is a successful outcome of treatment, etc.<p>What I see is that clinicians are quite willing to use relevant and effective evidence-based methods. One problems applying evidence to real-world practice arises out of the aggregate bases of evidence. Even if evidence-based approaches could work in typical cases, many patients vary enough from norms that following evidence-based recommendations doesn't work.<p>Furthermore it shouldn't be surprising when low-quality evidence gains corporate or governmental backing. When such promoted "standards" defy clinical observation it tarnishes the idea of evidence-based practice. An example is fairly recent recommendations that men over 70 shouldn't have routine PSA lab tests. Urologists will tell you about the hundreds of men they see with early stage prostate cancer detected by periodic PSA tests. Following the "evidence" would result in far more deaths and disability so it's ignored.<p>As the article points out corruption of "evidence-based medicine" has destroyed much of the promise the idea once held. Insurers, pharma houses, governments contribute to abuse of evidence to serve their own agendas. No doubt some fraction of practitioners have added to problems and that needs to be halted. But IMO regulators are quick to point fingers at all clinicians for failures of health care systems. Rather most providers would prefer to avoid corrupt "evidence" whereas real evidence is welcome to workers toiling in the trenches.
science is a pretty long term process. in practice results and consensus stabilizies after around 50 years or so.<p>the reason it takes so long is that the turnaround time for a single result in science is half a year to a year. imagine discussing something with someone and every sentence you speak could only be uttered after a year.<p>articles like OP always hinge on some short or medium understanding of science. they try to point out that the whole approach is wrong based on the intermediate results of the process. OP itself is part of this process and the reason why the results will be better and more stabilized a couple of decades from now.
Massive, major flaw in their argument.
"without seeing the raw data" is not true. At least in the UK.<p>All raw study data, published and un published must be provided before a medicine will be reimbursed. It is reviewed by teams who do their utmost to prove the med is worthless.<p>Same for the FDA afaik. All the data is generally "commercial in confidence" so any old twitteraty can not download and misinterpret it.<p>All trials must be registered on Clinicaltrials.gov or they cannot be used as evidence.<p>Publication bias is a well know issue, resolved for more than a decade. No idea how this article made it into the BMJ, smells like click bait.
One of the issues I’ve seen with EBP is that it’s often not necessarily science based. That is to say, prior plausibility derived from basic science isn’t fully incorporated, ergo undo weight is given to noise. You see with in almost any study of pseudoscientific modalities, where actual efficacy would require a drastic reformation of our fundamental,
very well tested models of the natural world. Why should a particularly strong one-off result for my made up pain treatment be afforded the same stature as that of an pharmacological agent with clear physiological pathways?
The problem is misaligned incentives.<p>You need to go after the "research trolls". Same as you would with patent trolls. Hit them where their money is.<p>Pass a law that anyone anyone ultimately funding or profiting off research can be sued by the public for double damages x cost of the research if :
- paper won't replicate
- paper sponsors & costs are not disclosed.
- paper does not include instructions to make data requests
- researcher does not release data within 30 days of request.
- paper publisher (whomever that could be, even faculty) failing to flag prominently within 30 days, any paper that has lost in court.<p>So if a university employs 1 researcher at X salary, and time spent on research is Y, the university can be sued for Y * X * 2 by Joe Schmo. Maybe this would be small claims court. Same would apply to any research created by big AG, Pharma, etc. If researcher uploads paper in his own personal website and forgets to flag it as flawed, he now pays the price too.<p>It would be necessary to cap disgorgement at 10x initial research cost. The point is to let the crowd hunt down garbage research, not bankrupt anyone for honest mistakes. I would also default to making the defense be rewarded by 2x incurred legal costs if they win case to ensure lawsuits have some merit.<p>This would immunize students if they are not paid to make research (but not PHDs that live off stipends), or random people doing research, out of goodwill.<p>Professionals would be very careful to publish garbage lest be fired from their jobs, and companies & researchers would think twice before pushing propaganda. No more research mills of BS.
There's so much money in cancer research - when I was a pharmacology/genetics researcher I was told to try to tie everything back to cancer for research papers and grant proposals.<p>And the oncology lab next door had the best equipment. We always had to borrow their stuff.<p>Idk maybe this is a good argument against private charity. Not to say that cancer research isn't important but from what I could tell, cancer researchers had an embarrassment of riches.
I think profit motive and regulatory capture are real problems but I don't think they're the only problems and maybe not the biggest.<p>For example, the FDA is generally agreed to have dropped the ball by dragging its feet on approving covid tests. I don't think profit motive or regulatory capture explain that. What does?<p>More transparency (as the authors recommend) sounds great but giving more power to regulatory bodies is no panacea.
It's not just corruption, it is an idea that seems very correct, but which is subtly wrong.<p>Take a substance like chlorine. It is put into municipal drinking water because it kills things - things that can kill us or harm us. It is credited with making municipal water a lot safer.<p>It has been shown to be safe and effective for most people.<p>The key is most people. Some people, at the edges of the bell curve, cannot tolerate chlorine. If they drink water with it, or bathe in water with it, it harms them. I have family members who have this sensitivity. Since moving to a place with well water, their health has improved immensely.<p>If you were to be guided only by studies that show the safety and effectiveness of the chlorine treatment, then you could overlook the fact that some people are outliers.<p>Evidence based medicine will guide you to things that will work for most people in a given situation. However, for a specific patient, you may need to depart from that evidence.<p>Limiting doctors to only evidence based approaches prevents them from treating specific patients.
It would appear that the authors are selling a book on this topic, which explains the BMJ article.<p>And I'm not sure their premise is all that accurate. If they think the FDA is in the pocket of pharmaceutical companies, that runs entirely counter to my experience. I can recall plenty of times where we'd suggest a change to a filing and the FDA response was "nope, changes denied". If you think the low level reviewers of submissions are secretly pulling the strings for Pfizer, you'd be wrong.<p>And in terms of the quality of publications - this is nothing new. There has always been a robustness to clinical trials. That's why the NCCN guidelines for cancer treatment actually rate the clinical evidence from Category 1 (strongest) to Category 3 (no evidence whatsoever).
Another great argument I have heard against EBM (or maybe rather against being religious about it) is that the studies and papers held to highest regard are made in circumstances that do not apply to most of healthcare: the studies might be done in the best hospitals like Johns Hopkins, with practically limitless human resources for the study, and very carefully selected patient groups. In a normal hospital situation you won’t have the time or the resources to dedicate the same care for each patient, and the patients might have other conditions (which would rule you out of the big studies).<p>Still, as a layman who is not a doctor, evidence based medicine sounds like a good idea, but as with everything, taking it to extreme is probably harmful
I have no idea if any of this is true, but it rings true and it reminds me of similar distortions of the integrity of scientific inquiry by the interest of industry, in my own field of study: artificial intelligence and machine learning.<p>And perhaps that's no surprise. It's the same universities that produce both kinds of research (and researcher) after all.
This is how dark ages start. Actual knowledge is watered down by corporate nonsense. Society loses confidence in the scientific establishment.
The organizing coordinate that took center stage in the age of enlightment will be lost.
Society still need some way to organize its cognition. Power and superstition will take center stage again.
In france we have this research director, Didier Raoult, who pushed for the use of Chloroquine as a treatment against COVID. He was the head of a research center dedicated to tropical diseases. This guy literally argued that the smaller the test sample, the better the result. This guy lost his job of director (not to mention investigation of research fraud), but he mades it very difficult for uneducated people to trust the vaccine.<p>Not to mention that I dated a biology scientist and teacher who did not want to get vaccinated. I heard 2 other scientist lost their jobs in a research lab in my city because of not wanting to get vaccinated.<p>So no matter what people will tell me, it seems that science is rife with people who should not have their credentials, despite high level education, universities, "merit based" grades, etc.<p>It reinforce my cynicism, because I had some scientific education, but I dropped and never reached a degree. It's what Pierre Bourdieu talks about, that degrees are a way of maintaining social classes. It's exactly what you hear in the movie "Good will hunting", that a degree is just a piece of paper, while people can just educate themselves by reading science books.
<a href="https://news.ycombinator.com/item?id=30761070#30796020" rel="nofollow">https://news.ycombinator.com/item?id=30761070#30796020</a><p>I put that article three days ago here, isn't there any moderation for double submissions?
I've been more or less of this opinion since watching this talk years ago by Dr. Jason Fung: <a href="https://www.youtube.com/watch?v=z6IO2DZjOkY" rel="nofollow">https://www.youtube.com/watch?v=z6IO2DZjOkY</a>
EBM suggests that swimming in a heated swimming pool (controlled studies) can be the same as swimming in open sea/ocean (applying the result in any possible case)
Cursory reading is : EBM would be great, but we can't trust the "E" in EBM because people selling the "M" in EBM have a vesting interest in producing fake data to justify selling more to the institutions hoping to do the "B".<p>It seems like the author think more "independant" parties would help (regulators ? white-label labs to do the testing instead of pharma labs ?)<p>All I can tell from the last two years is that I doubt people would really trust a "government agency" (or, anyone "paid by the taxpayers") more than "the corporate" lab.<p>(Case in point: the EU agencies that banned or suspended or restricted usage of some COVID-19 vaccines, at various points in the last year, are still mistrusted on the ground that they did not ban or suspend _one_ of the vaccines - which happens to be the most popular - hence "they must be in the pocket of lab X".)
Here in Québec the vaccine passport and the curfew was touted as the pinnacle of "following the science"(tm). Anyone contradicting their usefulness as effective sanitary measures were accused of "spreading misinformation"(tm).<p>The curfew was implemented twice. The vaccine passport was only recently removed.<p>Turns out, one FOIA request later, that they never consulted the data scientists of the public health institute. They made it all up.
>Scientific progress is thwarted by the ownership of data and knowledge because industry suppresses negative trial results, fails to report adverse events, and does not share raw data with the academic research community.<p>Not to derail the thread but this nicely encapsulates my reservations toward the COVID vaccines, and why I think mandates are egregiously unethical. The raw clinical trial data is still effectively a secret between pharma and the FDA, and both are under immense financial/political pressure to release a "safe and effective" product, not to mention the incestuous relationship between the ostensibly independent FDA and big pharma.