Bernadine Healy MD, cardiologist and former director of the National Institutes of Health (NIH), writes a periodic health column for the US news magazine, US News and World Report, to which I subscribe. Imagine my surprise when I read her latest column, in which she slams evidence-based medicine (EBM), based on a mish-mash of misunderstandings, innuendo, and illogic.
Misunderstandings
EBM is Based Mainly on Randomized Controlled Trials (RCTs) and Cost-Effectiveness Analysis? -
Healy wrote,
'best' evidence, gleaned mostly from randomized clinical trials and cost-benefit studies, is the basis for what docs should or shouldn't do.
A quick definition of EBM is medicine based on critical review of the best available evidence from clinical research, combined with clinical judgment, knowledge of biology, and patients' values and preferences. (See also: "Evidence-Based Medicine: What It Is and What It Isn't" from the 1996 British Medical Journal for a better explanation.) Although most EBM advocates regard evidence from clinical trials, all things being equal, as more trustworthy than evidence from observational research studies, it is a relatively common misperception that EBM disregards evidence from other kinds of studies. I have never heard of EBM placing any special emphasis on cost-benefit studies.
EBM Ignores Biology and Patient Preferences? -
Healy wrote,
EBM sees itself as a major shift away from traditional medicine that emphasizes the expertise of the medical profession. That includes knowledge of the underlying nature of disease, mechanisms of therapy, basic and clinical research, and physician experience.
As noted above, most EBM advocates see EBM as incorporating clinical expertise, knowledge of biology, and patients' values and concerns. This has been expressed in many of the seminal articles on EBM.
EBM is an Attack on Physicians? -
Healy wrote,
The autonomy and authority of the doctor, and the subsequent variability in care, are the problems that EBM wants to cure.
She also wrote,
According to Marc Rodwin, professor of law at Suffolk University Law School in Boston, EBM puts experts trained in social science, public health, epidemiology, and economic analysis on par with physicians and 'breaks the lock hold' the profession has over how medicine is practiced and compensated.
Most of the early EBM advocates were physicians. Most of us physicians who support EBM see it as a way to empower individual physicians (and other health professionals, and patients) to independently make judgments about the best way to manage particular medical problems based on best evidence and logic, rather than edicts from above. There are certainly some epidemiologists involved in the EBM movement, which makes sense. I have never seen a large number of sociologists, non-physician public health specialists, or economists involved in the movement, and have never been aware they were trying to deprofessionalize physicians.
EBM is Cook-Book Medicine? -
Healy wrote,
patients are forced into a one-size-fits-all straitjacket
EBM advocates have taken pains to show that EBM involves using the best available evidence to make decisions for individual patients, based on each patient's unique circ*mstances, clinical context, values and preferences.
EBM is Meant to Support a "Microfascist" Ideological Agenda? -
Healy first wrote,
EBM carries its own ideological and political agenda separate from its clinical purpose.
Later she seemingly approvingly wrote about
a scathing commentary on the EBM movement in the International Journal of Evidence-Based Healthcare by Dave Holmes, a professor of nursing at the University of Ottawa. He and his colleagues argue that EBM is 'outrageously exclusionary' and even 'microfascism' in the way it sifts knowledge. Though harsh, he makes a point....
I wrote an extensive post on the article by Holmes et al (here). I wonder if Healy has any idea that she was agreeing with an argument that based on the authority of post-modernists like Deleuze, Guttari, and Foucault (and based on little else). I also wonder if Healy had any idea that she was agreeing with an attack on the biomedical research basis of health care. (Holmes et al wrote, for example, "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.")
Innuendo and Illogic
By writing that EBM emphasizes the "'best' evidence," with the word best in quotes, Healy implies that EBM uses an arbitary method to assess evidence. Later she wrote that EBM was "anointing only a small sliver of research as best evidence and discarding or devaluing physician judgment and more than 90 percent of the medical literature." She seems to have no idea about how much effort EBM advocates have put into developing clear, objective, logical methods to assess clinical research. For an example, see the 600+ pages of Guyatt G, Rennie D. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice.
Although Healy clearly acknowledges that an important element of EBM is addressing clinical research, she wrote that EBM is a "major shift" away from medical expertise, and included within the scope of that expertise, "clinical research." That's illogical.
Healy attempted to illustrate her concerns with two examples, the controversies over screening mammography and using PSA to screen for prostate cancer. Both examples had to acknowledge that some of the EBM based concerns about these screening tests were based on knowledge of the biology of the relevant diseases, contradicting her earlier assertion that EBM ignores biology. And neither controversy was resolved in a way that suggested some fault with EBM concepts. Note that Healy wrote that the mammogram controversy was resolved by political power, not necessarily by clear consideration of what was actually best for patients.
Summary
In summary, it is too bad that Dr Healy used her bully pulpit for such a cheap set of shots at EBM. As a former NIH director, she should know better.
EBM is actually a way to use logic and evidence to figure out the best way to help patients. It is the antidote to all the vested interests, ideological as well as economic, that seek to influence health care.
In that vein, could Healy's writing have been affected by her fiduciary duties to protect the interests of Invacare, obligated by her membership on its board of directors? (Invacare makes durable medical devices.) Could her writings have been affected by Dr Floyd Loop, her husband's fiduciary duties to protect the interests of Tenet Healthcare, obligated by his membership on its board of directors? I would suggest that she should have disclosed such financial interests when writing her column.
