Jun 13, 2017

Science, democracy, and EBM

In a recent opinion article for the BMJ Richard Smith writes about EBM's principle of democratization:

Plus evidence based medicine is a democratising not an authoritarian force. The alternative to evidence based medicine is the expert based medicine that prevailed for centuries. With expert based medicine it is impossible for the student nurse to challenge the expert, but the evidence belongs to everybody. In the early days of evidence based medicine students and junior doctors were much more enthusiastic than the experts being displaced; they could examine the evidence and challenge the experts.

In a 2014 article, as a result of a series of interviews and panel discussion with founders and supporters of the EBM movement, for JAMA Smith et al. write:

Several of those interviewed identified when they began to be aware of the deficiencies in what might be called “expert-based medicine.” Brian Haynes, a professor of clinical epidemiology and biostatistics at McMaster University, began his journey to EBM in medical school in 1969 when he was lectured on the theories of Sigmund Freud. He asked the lecturer for the evidence that the theories were “true.” The lecturer answered candidly that he did not think that there was any evidence and that he had been sent by the chair of the department, a Freudian, to give the lecture. “I had,” says Haynes, “an intense tingle in my body as I wondered how much of my medical education was based on unproved theories”.


Subsequently, JAMA (through one of us, D.R.) established relationships with Sackett and Guyatt that led eventually to 2 pioneering series of articles in JAMA. The first was The Rational Clinical Examination,12,13 which was intended “to make a science out of taking a history and doing an examination.” These enterprises are fundamental to medicine but had not been scientifically studied. The second was the Users’ Guides to the Medical Literature, which was designed to help clinicians keep up to date by enabling them to interpret the burgeoning medical literature and to facilitate clinical decisions based on evidence from the medical literature rather than hope or authority.14


Muir Gray, a public health physician and UK National Health Service manager, and Iain Chalmers were both inspired by the program at McMaster and persuaded Sackett to move to Oxford in 1994, where he worked as a clinician and was also director of the Centre for Evidence-Based Medicine. Sackett worked to spread EBM to the rest of the United Kingdom, Europe, and beyond. He visited most of the UK district general hospitals and many in Europe and would begin his visit by doing a round on patients admitted the previous night with young physicians and showing EBM in action. The young physicians realized that they could challenge their seniors in away that was not possible with expert-based medicine. It was liberating and democratizing.

Skepticism has been one of the main drivers in the establishment of evidence-based medicine since its origins. This aligns well with the principles of science and democracy as Carl Sagan reminded us:

The values of science and the values of democracy are concordant, in many cases indistinguishable. Science and democracy began - in their civilized incarnations - in the same time and place, Greece in the seventh and sixth centuries BC. Science confers power on anyone who takes the trouble to learn it (although too many have been systematically prevented from doing so). Science thrives on, indeed requires, the free exchange of ideas; its values are antithetical to secrecy. Science holds to no special vantage points or privileged positions. Both science and democracy encourage unconventional opinions and vigorous debate. Both demand adequate reason, coherent argument, rigorous standards of evidence and honesty. Science is a way to call the bluff of those who only pretend to knowledge. It is a bulwark against mysticism, against superstition, against religion misapplied to where it has no business being. If we're true to its values, it can tell us when we're being lied to. It provides a mid-course correction to our mistakes. The more widespread its language, rules and methods, the better chance we have of preserving what Thomas Jefferson and his colleagues had in mind. But democracy can also be subverted more thoroughly through the products of science than any pre-industrial demagogue ever dreamed.

Finding the occasional straw of truth awash in a great ocean of confusion and bamboozle requires vigilance, dedication and courage. But if we don't practise these tough habits of thought, we cannot hope to solve the truly serious problems that face us and we risk becoming a nation of suckers, a world of suckers, up for grabs by the next charlatan who saunters along.(pp. 41-42)

As long as medicine is taught without teaching how science works evidence and skepticism will be seen as a challenges rather than a normal feature of its best practice. But as Ioannidis has already told us medicine has been hijacked.

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1. You should attempt to re-express your target’s position so clearly, vividly, and fairly that your target says, “Thanks, I wish I’d thought of putting it that way.
2. You should list any points of agreement (especially if they are not matters of general or widespread agreement).
3. You should mention anything you have learned from your target.
4. Only then are you permitted to say so much as a word of rebuttal or criticism.
Daniel Dennett, Intuition pumps and other tools for thinking.

Valid criticism is doing you a favor. - Carl Sagan