11 ms·

The Rise and Fall of Evidence Based Medicine (1998) [pdf]

115 points by quickfox 3y ago

satellite2 3y ago
https://en.wikipedia.org/wiki/Bruce_Charlton https://en.wikipedia.org/wiki/Bruce_Charlton
cactusplant7374 3y ago
I thought all medicine is evidence based as long as it’s not homeopathic or chiropractic?
- Vecr 3y ago
  Not really, people probably have better examples but doctors quite often don't actually try to figure out what antibiotic is the best, they just pick something for no real reason (they remember the name) and write a prescription. There are studies on what antibiotic to use quite a lot of the time, but that takes effort. You get a Z-Pack, and you get a Z-Pack, etc...
  - dekhn 3y ago
    Probably one of the best known examples is the establishment as helicobacter pylori as the ultimate cause of ulcers, rather than stress, spicy food, and low pH. Marshall won the nobel prize for this, and it's often touted as a situation where there was a lot of initial non-scientific resistence "of course we know it's stress..."
- hvs 3y ago
  https://pubmed.ncbi.nlm.nih.gov/9276585/ https://pubmed.ncbi.nlm.nih.gov/9276585/ I conclude that attempts to classify medical decisions as justified or unjustified by scientific evidence have no foundation in logic and that the term 'evidence-based medicine' is logically indistinguishable from the term 'medicine'. The use of the term 'evidence-based medicine' calls for a new type of authoritarianism in medical practice.
- 5040 3y ago
  The ancient medical schools varied quite a bit when it came to questions of evidence. Something to think about perhaps. >The Empiricists were sceptics in their attitude to causes, thinking that observation and report of evident conditions and their cures was sufficient for medical science, and thus eschewing causal theory. Rationalist doctors attacked the inadequate methodology of the Empiricists, and they try to explain why the antecedent cause should bring on such and such an effect, while emphasizing the need to decide rationally the proper use of induction, and the relevancy of similarities. The Methodists treat as irrelevant antecedent causes or factors, and they recognized just two pathological conditions—relaxation and constriction; the doctor's concern is to determine by direct observation in which state is the body.
- pella 3y ago
  "(effect sizes) Some of our favorite medications, including statins, anticholinergics, and bisphosphonates, don’t reach the 0.50 level. And many more, including triptans, benzodiazepines (!), and Ritalin (!!) don’t reach 0.875." "There’s no anti-ibuprofen lobby trying to rile people up about NSAIDs, so nobody’s pointed out that this is “clinically insignificant”. But by traditional standards, it is!" read more: All Medications Are Insignificant In The Eyes Of God And Traditional Effect Size Criteria ( MAY 31, 2023 ) https://astralcodexten.substack.com/p/all-medications-are-insignificant https://astralcodexten.substack.com/p/all-medications-are-in...
- bedobi 3y ago
  homeopathic medicine, chiropractic medicine, folk medicine, traditional medicine, osteopathic medicine, crystal healing medicine... you can make an infinite list of nonsense and if you want to disambiguate and say "evidence based medicine" to refer to actual medicine, they can just make it "evidence based homeopathic medicine" and so on and so on can't beat these people
  - msla 3y ago
    > they can just make it "evidence based homeopathic medicine" and so on and so on Only if the homeopaths lie about the evidence.
    - smegsicle 3y ago
      curious how combative some people seem to get about homeopathics when placebo has been shown to have consistent positive effect, without side effects, for almost every illness
      - metalliqaz 3y ago
        they aren't honestly trying to sell placebos (like Zeebo). They are marketing actual 'cures' for serious maladies that could respond to real treatments
      - technothrasher 3y ago
        If placebos don’t have side effects, why do the control groups in placebo-based trials always report side effects? And given that “homeopathic” to most casually informed people is the same as “naturopathic”, what those people are taking are not necessarily harmless placebos. As for your “almost every illness,” that’s just meaningless hyperbole.
      - msla 3y ago
        Yes, it's 'curious' how people with a sense of basic decency get 'combative' when the Alternative Medicine Industry lies to them to sell useless treatments for diseases that could actually be improved by real medicine. It really is odd how that works, isn't it?
- Dma54rhs 3y ago
  It's often based on authority and tradition, evidence based is a fairly new idea.
janeway 3y ago
I am sure I miss the context but I guess the point is that authors were sick of hearing about the promise of statistical analysis and epidemiology which will outperform classical medical approach - slandering the BMJ several times for some reason. Even today we see some hanger-ons who assert that their way is the best way - that they know from personal medical cases and their opinion and interpretation is more valuable than some statistical prediction. Well, if I have understood their sentiment correctly; facts are facts. Today the best medical care in the world is driven by data-based adaption rather than subjective opinion. If a treatment has a robust statistical impact it will be preferred. If new methods produce outcomes no better than random noise then we must agree that they are not better. If the physician has anecdotes about why they think some trick works best then - in the words of Pearson - “statistics on the table, please”. I am sorry to make the joke but it seems apt: “Dr Charlatan disgruntled about needing evidence for science”.
- Retric 3y ago
  Yes and no, Statistics have an inherent weakness when you don’t have consistent buckets to place everything into. If individual specialists classify cases differently they really can see statistically valid numbers from relatively few cases where double blind studies using different classification criteria see improvements below the noise floor.
  - mjburgess 3y ago
    Also, largely, there is no scientific evidence for the vast majority of problems. The only evidential basis for causal analysis are experiments where (1) you intervene to bring about the cause deterministically; and (2) where you control all confounding causes. Those conditions are impossible to meet for the vast majority of interactions in complex systems, such as people & medicine. If you run associative statistics on counfounded data collected in observational studies, you may as well correlate star signs with outcomes -- no doubt people being treated under winter signs will do worse than those under gemini. Astrology QED.
    - LorenPechtel 3y ago
jbandela1 3y ago
Evidence Based Medicine is one of those things that is a good thing, but was pushed so hard by its proponents that it ended up overemphasizing a particular kind of study as the only real way to know things in medicine. Yes, absolutely, medicine should be evidence based. Yes, large randomized, double blind, placebo controlled studies provide a lot of information. However, there are limitations with these kinds of studies. First, it may not be ethical or practical to study some things in this manner. For example, antibiotics for bacterial pneumonia has not had a randomized, double blind, placebo controlled study. Famously, there was an article discussing how parachutes in jumping out of airplanes had not been subject to a randomized, double blind, placebo controlled study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/ Later, somebody did that study: https://www.bmj.com/content/363/bmj.k5094 https://www.bmj.com/content/363/bmj.k5094 and found that parachutes made no difference, but it is not applicable to any real world case where you would use a parachute. Which illustrates the second issue with evidence based medicine. Many times, the large trials's main thing they are measuring are different than what you really want to know, or the population they studied has significant differences from the patient who is right in front of you. How to apply the results of the large study to the individual patient in front of you is still more of an art than a science. Finally, I think there is the example from machine learning. It has turned out that instead of creating more and more rules, feeding lots and lots of data to a neural network ends up performing better in a lot of machine learning cases. In a similar way, an experienced physician who has treated thousands of patients over decades has a lot of implicit knowledge and patterns stored in their (human) neural networks. Yes, these decisions should be informed by the results of trials, but they should not be discounted, which I think that Evidence Based Medicine did in at least a small part. During my residency, I worked with physicians who would examine and talk with a patient and tell me that something is not right and to do more extensive tests which would end up unearthing a hidden infection or other problem that we were able to treat before it caused major problems. They were seeing subtle patterns from decades of experience that might not even be fully captured in the patient's chart, much less a clinical trial without thousands of participants. So yes, these clinical trials are a very important base for knowledge. But so is physician judgment and experience. Source: I am a physician.
- 3y ago
hospitalJail 3y ago
I'd love the idea of science based medicine. There are a few issues: >HIPPA has made it basically impossible to do science in Medicine without being part of the establishment >The medical cartels hate change, its bad for business, they actively lobby against change and competition. They want authority based medicine. >The scientist responsible for the discovery and treatment of an issue, can't even legally practice. We should entirely be blaming the medical cartels here. They have been terrible for our health, technology, and wallets.
- ethanbond 3y ago
  What exactly is HIPAA’s role here? With or without HIPAA, medical institutions don’t want to share their data, especially not the ones with good data because they do their own research.
  - chimeracoder 3y ago
    > What exactly is HIPAA’s role here? With or without HIPAA, medical institutions don’t want to share their data, especially not the ones with good data because they do their own research. I agree that OP's thesis doesn't make much sense. HIPAA provides a legal framework for institutions to share data without liability[0]. It doesn't apply at all to non-"institutional" actors (in the way that OP seems to be using the word "institutional"). HIPAA is an extra cost for the big players, but there's little, if anything, that it prevents them from doing which they would otherwise want to do. [0] More precisely, it provides a framework for capping liability exposure for institutions
    - spondylosaurus 3y ago
      As a rule of thumb, I find it's usually safe to dismiss criticism of HIPAA from anyone who misspells it as HIPPA. Not knowing that it's an acronym for Health Insurance Portability and Accountability Act (emphasis on portability there, as you pointed out!) tends to be a sign that you don't know what the hell HIPAA is or is for. "HIPPA," on the other hand, is an ever-convenient boogeyman you can invoke in all kinds of situations.
neverrroot 3y ago
[flagged]
- metalliqaz 3y ago
  [flagged]
  - dang 3y ago
    Regardless of what the GP said, you broke the site guidelines here, which ask you to edit out swipes (like "What are you talking about"). Your comment would be just fine without that bit. We've to ask you this kind of thing more than once before. If you wouldn't mind reviewing https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html and taking the intended spirit of the site more to heart, we'd be grateful.
    - metalliqaz 3y ago
      this is heavy handed moderation. I actually wanted to know what he's talking about, as in, to what approval process is GP referring? And when faced with what appeared to be actual vaccine misinformation, you decide to come down on my post instead? do you just not like my vernacular? Have a problem with my username?
      - dang 3y ago
        "What are you talking about" is a common swipe and guaranteed to land as such. It isn't used in contemporary English to ask neutrally what someone is referring to. If that's what you wanted to do, there are plenty of other phrases to use. > And when faced with what appeared to be actual vaccine misinformation, you decide to come down on my post instead? By the time I saw the GP post, it had been replaced with "[deleted]", so it wasn't a question of "instead". (It's not a good practice to replace a comment with "[deleted]", but that's a different issue.) As for "misinformation", people mostly use that term to mean something they strongly disagree with. It isn't against HN's rules to be wrong. Possibly the GP did break HN's rules in some other way, but that's independent of whether you broke the rules (which you did). Users here need to follow the rules regardless of how bad another post is or you feel it is.
pella 3y ago
(2020) Will COVID-19 be evidence-based medicine’s nemesis? https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003266 https://journals.plos.org/plosmedicine/article?id=10.1371/jo... "It is surely time to turn to a more fit-for-purpose scientific paradigm. Complex adaptive systems theory proposes that precise quantification of particular cause-effect relationships is both impossible (because such relationships are not constant and cannot be meaningfully isolated) and unnecessary (because what matters is what emerges in a particular real-world situation). This paradigm proposes that where multiple factors are interacting in dynamic and unpredictable ways, naturalistic methods and rapid-cycle evaluation are the preferred study design. The 20th-century logic of evidence-based medicine, in which scientists pursued the goals of certainty, predictability and linear causality, remains useful in some circumstances (for example, the drug and vaccine trials referred to above). But at a population and system level, we need to embrace 21st-century epistemology and methods to study how best to cope with uncertainty, unpredictability and non-linear causality [16]. In a complex system, the question driving scientific inquiry is not “what is the effect size and is it statistically significant once other variables have been controlled for?” but “does this intervention contribute, along with other factors, to a desirable outcome?”. Multiple interventions might each contribute to an overall beneficial effect through heterogeneous effects on disparate causal pathways, even though none would have a statistically significant impact on any predefined variable [11]. To illuminate such influences, we need to apply research designs that foreground dynamic interactions and emergence. These include in-depth, mixed-method case studies (primary research) and narrative reviews (secondary research) that tease out interconnections and highlight generative causality across the system [16, 17]." table1: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003266 https://journals.plos.org/plosmedicine/article?id=10.1371/jo...
- kspacewalk2 3y ago
  Sounds extremely susceptible to quackery and hand-waving appeals to authority.
  - deleted 3y ago
    [deleted]
  - 3y ago
rgbgraph 3y ago
There was a great book about Evidence Based Medicine, from a woman out of Oxford, I read a long while ago. Can't for the life of me remember the name, but Oxford does have a center for "Evidence Based Medicine," and the whole idea has been slowly coming back into fashion. Instead, all I can recommend is a collection of essays -- loosely -- related to the subject: Where's the Evidence?, Silverman --- On another note, someone who's gone down the pharmaceutical research rabbit hole and concluded a lot of it is "bunkum" (e.g. statins, anti-depressants, and so on), would do well to look into surgery next -- especially that of surgical implants. Some of worth looking into: joint replacements, joint and spinal fusions, angioplasties. Of note: spinal fusions were not brought about on any scientific or experimental bases, but on hunches from surgeons (damnable bunch). Many do result in a reduction in pain, but it does bring to question how much of it is simply "placebo." There were a few experiments in this realm of doing double blind (or single blind, it escapes me right now) studies on back surgeries, that showed evidence the placebo effect was involved. The simple act of being put under anaesthesia, and convinced one had gotten "treatment," resulted in reductions in pain for those who came in for spinal surgery. I do wish more research would be done into the placebo effect, and doctors would stop faffing about in self-righteousness (though having an air of expertise and authority does impact the placebo effect positively). And I don't mean in a "the placebo effect exists and is usable as a treatment" way, but in a "the placebo effect exists, and here is how it works in the body." That would be very interesting. Long ago I read a few papers on the placebo effect in regulating blood pressure via regulation of a certain chemical (it could have been a hormone like renin, but I can't recall). At the time, I thought the autonomic nervous system would be a good avenue to research to better figure this out (it would be a convenient explanation for how the placebo effect works: activating the nerves in the kidneys via the cross-talk from the central nervous system to excrete certain hormones). If it can affect the kidneys, what other bodily systems can it impact? The possibilities are not endless, but rather exciting. I believe the "placebo effect" is the reason chiropractors are so popular, in spite of there being no real physical evidence as to why their treatments help people.
- LorenPechtel 3y ago
  I do agree things should be studied but you have to be careful with it. Studies are big and expensive and things can be missed. Remember the big flap over hormone replacement therapy being shown harmful? Oops--all it really showed is what we knew all along, estrogen is risky for fat women.
bjornsing 3y ago
The main flaw in EBM is that it inverts the scientific method: It’s no longer about hypotheses and falsification. Instead it’s about “scientifically proven facts” (aka “evidence”). Sadly this aligns much better with our dogmatic instinctive understanding of knowledge as a set of agreed truths.
- haldujai 3y ago
  It's because medicine is as much an art as a science given the impossibility of problem space, also whenever we ignore evidence we end up harming/killing people.
- deltaninenine 3y ago
  It is true that in science nothing can be proven but this fact doesn't apply if you think in terms of statistics. Science is broad and doesn't always give answers in terms of a boolean falsification. You can be given a ratio as the result. This result is usually A probability established to a degree within the context of a sample size. This is the closest thing to proof that science can offer and we just go with it. EBM goes a bit further then just a probability in the context of a sample size. There's a further degree of rigor in the qualitative sense that the probability is causal and not correlative. It's subtle but causality is even closer to proof then a correlative study.
user3939382 3y ago
Good lecture on this topic https://youtu.be/z6IO2DZjOkY https://youtu.be/z6IO2DZjOkY
DoreenMichele 3y ago
Ah, the human as a specimen in a petri dish approach to so-called health care. Flies directly in the face of study after study after study that says: diet and lifestyle are major factors in all deadly diseases. Probably driven by modern tech, completely inadvertently, because x-ray machines and MRIs and such demand that the patient go to the clinic or hospital rather than the doctor going to the patient's home. Star Trek's Dr. McCoy and his tricorder was a dream of tech that you could carry in the proverbial little black bag. We aren't there and have forgotten a lot of important principles in the process of pursuing shiny tech. But it's generally a bad idea to critique any of that. Gets one nothing but hatred.
- dekhn 3y ago
  I think this is a pretty thoughtless statement. Ashkenazi women often have genetic mutations that cause them to get breast cancer and the cancer prognosis is much worse than average. This cannot be addressed by diet or lifestyle. However, genomic sequencing detected common patterns that can be tested for, and with that information, women can make informed choices about treatment or other actions, ideally well before they ever have a malignant tumor. I won't disagree that we could do a lot better overall with large-scale changes in diet and lifestyle. But it still would leave a lot of people dying of heart disease and cancer as well as infectious diseases. Those x-ray machines and MRI machines make a huge difference for people with internal injuries as well. No amount of diet and lifestyle will heal a shattered bone.
  - DoreenMichele 3y ago
    That's a wild misreading of my comment.
    - dekhn 3y ago
      All the comments I make on Hacker News are done in good faith and assume good will on the part of the person I'm replying to. If you really think I misread, please rewrite what you wrote; as far as I can tell, I read and interpreted it clearly. It's best if you come out and say things directly, while your statement's thesis isn't entirely clear, but I read it as: Flies directly in the face of study after study after study that says: diet and lifestyle are major factors in all deadly diseases. <- yes, this is true. However, it's not a useful statement when criticizing medicine based on technology. Even if everybody in the world had a "perfect" diet and lifestyle, it wouldn't address the majority of diseases at a very large scale. Probably driven by modern tech, completely inadvertently, because x-ray machines and MRIs and such demand that the patient go to the clinic or hospital rather than the doctor going to the patient's home. <- OK, not sure what to say about this other than, it's an unfair comparison; there's plenty of in-home care and in-home doctors can't resolve a wide range of issues at a person's house. It also brings risk to the doctor, as well as causing them to spend their day travelling around. Star Trek's Dr. McCoy and his tricorder was a dream of tech that you could carry in the proverbial little black bag. We aren't there and have forgotten a lot of important principles in the process of pursuing shiny tech. <- actually, doctors and medical researchers, for all that they pursue shiny tech, still mostly have a good appreciation for "important principles". For example, I watched my surgeon count the sponges that they took out of my spouse after surgery, to make sure they hadn't left any in (this was a surprisingly common problem with surgeries). They don't try to make a "sponge detector machine". That's just one example out of millions; if you've followed doctors on Rounds, you'll see that most of what they do isn't technology. But it's generally a bad idea to critique any of that. Gets one nothing but hatred. <- I explicitly wrote my comment to be friendly, fact-based, and make my thesis as clear as possible. If you're going around pointing out that "medical basics that we've known for a while matter", nobody is going to agree with you. But if you attack doctors/medical researchers the way you do, you instance cause people to interpret you as somebody to argue with.
sampo 3y ago
Here is a 2022 critique of the narrow-mindedness of Evidence Based Medicine, by an Oxford professor and the author of what is perhaps the most widely used textbook on Evidence Based Medicine: https://ebm.bmj.com/content/27/5/253 https://ebm.bmj.com/content/27/5/253
epgui 3y ago
I'm a biochemist with a medical background, and FWIW, I think this is a garbage article. Hardly even worth commenting on. =/

115 points by quickfox 3y ago

satellite2 3y ago

https://en.wikipedia.org/wiki/Bruce_Charlton https://en.wikipedia.org/wiki/Bruce_Charlton

cactusplant7374 3y ago

I thought all medicine is evidence based as long as it’s not homeopathic or chiropractic?

Vecr 3y ago
Not really, people probably have better examples but doctors quite often don't actually try to figure out what antibiotic is the best, they just pick something for no real reason (they remember the name) and write a prescription. There are studies on what antibiotic to use quite a lot of the time, but that takes effort. You get a Z-Pack, and you get a Z-Pack, etc...
- dekhn 3y ago
  Probably one of the best known examples is the establishment as helicobacter pylori as the ultimate cause of ulcers, rather than stress, spicy food, and low pH. Marshall won the nobel prize for this, and it's often touted as a situation where there was a lot of initial non-scientific resistence "of course we know it's stress..."
hvs 3y ago
https://pubmed.ncbi.nlm.nih.gov/9276585/ https://pubmed.ncbi.nlm.nih.gov/9276585/ I conclude that attempts to classify medical decisions as justified or unjustified by scientific evidence have no foundation in logic and that the term 'evidence-based medicine' is logically indistinguishable from the term 'medicine'. The use of the term 'evidence-based medicine' calls for a new type of authoritarianism in medical practice.
5040 3y ago
The ancient medical schools varied quite a bit when it came to questions of evidence. Something to think about perhaps. >The Empiricists were sceptics in their attitude to causes, thinking that observation and report of evident conditions and their cures was sufficient for medical science, and thus eschewing causal theory. Rationalist doctors attacked the inadequate methodology of the Empiricists, and they try to explain why the antecedent cause should bring on such and such an effect, while emphasizing the need to decide rationally the proper use of induction, and the relevancy of similarities. The Methodists treat as irrelevant antecedent causes or factors, and they recognized just two pathological conditions—relaxation and constriction; the doctor's concern is to determine by direct observation in which state is the body.
pella 3y ago
"(effect sizes) Some of our favorite medications, including statins, anticholinergics, and bisphosphonates, don’t reach the 0.50 level. And many more, including triptans, benzodiazepines (!), and Ritalin (!!) don’t reach 0.875." "There’s no anti-ibuprofen lobby trying to rile people up about NSAIDs, so nobody’s pointed out that this is “clinically insignificant”. But by traditional standards, it is!" read more: All Medications Are Insignificant In The Eyes Of God And Traditional Effect Size Criteria ( MAY 31, 2023 ) https://astralcodexten.substack.com/p/all-medications-are-insignificant https://astralcodexten.substack.com/p/all-medications-are-in...
bedobi 3y ago
homeopathic medicine, chiropractic medicine, folk medicine, traditional medicine, osteopathic medicine, crystal healing medicine... you can make an infinite list of nonsense and if you want to disambiguate and say "evidence based medicine" to refer to actual medicine, they can just make it "evidence based homeopathic medicine" and so on and so on can't beat these people
- msla 3y ago
  > they can just make it "evidence based homeopathic medicine" and so on and so on Only if the homeopaths lie about the evidence.
  - smegsicle 3y ago
    curious how combative some people seem to get about homeopathics when placebo has been shown to have consistent positive effect, without side effects, for almost every illness
    - metalliqaz 3y ago
      they aren't honestly trying to sell placebos (like Zeebo). They are marketing actual 'cures' for serious maladies that could respond to real treatments
    - technothrasher 3y ago
      If placebos don’t have side effects, why do the control groups in placebo-based trials always report side effects? And given that “homeopathic” to most casually informed people is the same as “naturopathic”, what those people are taking are not necessarily harmless placebos. As for your “almost every illness,” that’s just meaningless hyperbole.
    - msla 3y ago
      Yes, it's 'curious' how people with a sense of basic decency get 'combative' when the Alternative Medicine Industry lies to them to sell useless treatments for diseases that could actually be improved by real medicine. It really is odd how that works, isn't it?
Dma54rhs 3y ago
It's often based on authority and tradition, evidence based is a fairly new idea.

janeway 3y ago

I am sure I miss the context but I guess the point is that authors were sick of hearing about the promise of statistical analysis and epidemiology which will outperform classical medical approach - slandering the BMJ several times for some reason. Even today we see some hanger-ons who assert that their way is the best way - that they know from personal medical cases and their opinion and interpretation is more valuable than some statistical prediction. Well, if I have understood their sentiment correctly; facts are facts. Today the best medical care in the world is driven by data-based adaption rather than subjective opinion. If a treatment has a robust statistical impact it will be preferred. If new methods produce outcomes no better than random noise then we must agree that they are not better. If the physician has anecdotes about why they think some trick works best then - in the words of Pearson - “statistics on the table, please”. I am sorry to make the joke but it seems apt: “Dr Charlatan disgruntled about needing evidence for science”.

Retric 3y ago
Yes and no, Statistics have an inherent weakness when you don’t have consistent buckets to place everything into. If individual specialists classify cases differently they really can see statistically valid numbers from relatively few cases where double blind studies using different classification criteria see improvements below the noise floor.
- mjburgess 3y ago
  Also, largely, there is no scientific evidence for the vast majority of problems. The only evidential basis for causal analysis are experiments where (1) you intervene to bring about the cause deterministically; and (2) where you control all confounding causes. Those conditions are impossible to meet for the vast majority of interactions in complex systems, such as people & medicine. If you run associative statistics on counfounded data collected in observational studies, you may as well correlate star signs with outcomes -- no doubt people being treated under winter signs will do worse than those under gemini. Astrology QED.
  - LorenPechtel 3y ago

jbandela1 3y ago

Evidence Based Medicine is one of those things that is a good thing, but was pushed so hard by its proponents that it ended up overemphasizing a particular kind of study as the only real way to know things in medicine. Yes, absolutely, medicine should be evidence based. Yes, large randomized, double blind, placebo controlled studies provide a lot of information. However, there are limitations with these kinds of studies. First, it may not be ethical or practical to study some things in this manner. For example, antibiotics for bacterial pneumonia has not had a randomized, double blind, placebo controlled study. Famously, there was an article discussing how parachutes in jumping out of airplanes had not been subject to a randomized, double blind, placebo controlled study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/ Later, somebody did that study: https://www.bmj.com/content/363/bmj.k5094 https://www.bmj.com/content/363/bmj.k5094 and found that parachutes made no difference, but it is not applicable to any real world case where you would use a parachute. Which illustrates the second issue with evidence based medicine. Many times, the large trials's main thing they are measuring are different than what you really want to know, or the population they studied has significant differences from the patient who is right in front of you. How to apply the results of the large study to the individual patient in front of you is still more of an art than a science. Finally, I think there is the example from machine learning. It has turned out that instead of creating more and more rules, feeding lots and lots of data to a neural network ends up performing better in a lot of machine learning cases. In a similar way, an experienced physician who has treated thousands of patients over decades has a lot of implicit knowledge and patterns stored in their (human) neural networks. Yes, these decisions should be informed by the results of trials, but they should not be discounted, which I think that Evidence Based Medicine did in at least a small part. During my residency, I worked with physicians who would examine and talk with a patient and tell me that something is not right and to do more extensive tests which would end up unearthing a hidden infection or other problem that we were able to treat before it caused major problems. They were seeing subtle patterns from decades of experience that might not even be fully captured in the patient's chart, much less a clinical trial without thousands of participants. So yes, these clinical trials are a very important base for knowledge. But so is physician judgment and experience. Source: I am a physician.

3y ago

hospitalJail 3y ago

I'd love the idea of science based medicine. There are a few issues: >HIPPA has made it basically impossible to do science in Medicine without being part of the establishment >The medical cartels hate change, its bad for business, they actively lobby against change and competition. They want authority based medicine. >The scientist responsible for the discovery and treatment of an issue, can't even legally practice. We should entirely be blaming the medical cartels here. They have been terrible for our health, technology, and wallets.

ethanbond 3y ago
What exactly is HIPAA’s role here? With or without HIPAA, medical institutions don’t want to share their data, especially not the ones with good data because they do their own research.
- chimeracoder 3y ago
  > What exactly is HIPAA’s role here? With or without HIPAA, medical institutions don’t want to share their data, especially not the ones with good data because they do their own research. I agree that OP's thesis doesn't make much sense. HIPAA provides a legal framework for institutions to share data without liability[0]. It doesn't apply at all to non-"institutional" actors (in the way that OP seems to be using the word "institutional"). HIPAA is an extra cost for the big players, but there's little, if anything, that it prevents them from doing which they would otherwise want to do. [0] More precisely, it provides a framework for capping liability exposure for institutions
  - spondylosaurus 3y ago
    As a rule of thumb, I find it's usually safe to dismiss criticism of HIPAA from anyone who misspells it as HIPPA. Not knowing that it's an acronym for Health Insurance Portability and Accountability Act (emphasis on portability there, as you pointed out!) tends to be a sign that you don't know what the hell HIPAA is or is for. "HIPPA," on the other hand, is an ever-convenient boogeyman you can invoke in all kinds of situations.

neverrroot 3y ago

[flagged]

metalliqaz 3y ago
[flagged]
- dang 3y ago
  Regardless of what the GP said, you broke the site guidelines here, which ask you to edit out swipes (like "What are you talking about"). Your comment would be just fine without that bit. We've to ask you this kind of thing more than once before. If you wouldn't mind reviewing https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html and taking the intended spirit of the site more to heart, we'd be grateful.
  - metalliqaz 3y ago
    this is heavy handed moderation. I actually wanted to know what he's talking about, as in, to what approval process is GP referring? And when faced with what appeared to be actual vaccine misinformation, you decide to come down on my post instead? do you just not like my vernacular? Have a problem with my username?
    - dang 3y ago
      "What are you talking about" is a common swipe and guaranteed to land as such. It isn't used in contemporary English to ask neutrally what someone is referring to. If that's what you wanted to do, there are plenty of other phrases to use. > And when faced with what appeared to be actual vaccine misinformation, you decide to come down on my post instead? By the time I saw the GP post, it had been replaced with "[deleted]", so it wasn't a question of "instead". (It's not a good practice to replace a comment with "[deleted]", but that's a different issue.) As for "misinformation", people mostly use that term to mean something they strongly disagree with. It isn't against HN's rules to be wrong. Possibly the GP did break HN's rules in some other way, but that's independent of whether you broke the rules (which you did). Users here need to follow the rules regardless of how bad another post is or you feel it is.

pella 3y ago

(2020) Will COVID-19 be evidence-based medicine’s nemesis? https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003266 https://journals.plos.org/plosmedicine/article?id=10.1371/jo... "It is surely time to turn to a more fit-for-purpose scientific paradigm. Complex adaptive systems theory proposes that precise quantification of particular cause-effect relationships is both impossible (because such relationships are not constant and cannot be meaningfully isolated) and unnecessary (because what matters is what emerges in a particular real-world situation). This paradigm proposes that where multiple factors are interacting in dynamic and unpredictable ways, naturalistic methods and rapid-cycle evaluation are the preferred study design. The 20th-century logic of evidence-based medicine, in which scientists pursued the goals of certainty, predictability and linear causality, remains useful in some circumstances (for example, the drug and vaccine trials referred to above). But at a population and system level, we need to embrace 21st-century epistemology and methods to study how best to cope with uncertainty, unpredictability and non-linear causality [16]. In a complex system, the question driving scientific inquiry is not “what is the effect size and is it statistically significant once other variables have been controlled for?” but “does this intervention contribute, along with other factors, to a desirable outcome?”. Multiple interventions might each contribute to an overall beneficial effect through heterogeneous effects on disparate causal pathways, even though none would have a statistically significant impact on any predefined variable [11]. To illuminate such influences, we need to apply research designs that foreground dynamic interactions and emergence. These include in-depth, mixed-method case studies (primary research) and narrative reviews (secondary research) that tease out interconnections and highlight generative causality across the system [16, 17]." table1: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003266 https://journals.plos.org/plosmedicine/article?id=10.1371/jo...

kspacewalk2 3y ago
Sounds extremely susceptible to quackery and hand-waving appeals to authority.
- deleted 3y ago
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rgbgraph 3y ago

There was a great book about Evidence Based Medicine, from a woman out of Oxford, I read a long while ago. Can't for the life of me remember the name, but Oxford does have a center for "Evidence Based Medicine," and the whole idea has been slowly coming back into fashion. Instead, all I can recommend is a collection of essays -- loosely -- related to the subject: Where's the Evidence?, Silverman --- On another note, someone who's gone down the pharmaceutical research rabbit hole and concluded a lot of it is "bunkum" (e.g. statins, anti-depressants, and so on), would do well to look into surgery next -- especially that of surgical implants. Some of worth looking into: joint replacements, joint and spinal fusions, angioplasties. Of note: spinal fusions were not brought about on any scientific or experimental bases, but on hunches from surgeons (damnable bunch). Many do result in a reduction in pain, but it does bring to question how much of it is simply "placebo." There were a few experiments in this realm of doing double blind (or single blind, it escapes me right now) studies on back surgeries, that showed evidence the placebo effect was involved. The simple act of being put under anaesthesia, and convinced one had gotten "treatment," resulted in reductions in pain for those who came in for spinal surgery. I do wish more research would be done into the placebo effect, and doctors would stop faffing about in self-righteousness (though having an air of expertise and authority does impact the placebo effect positively). And I don't mean in a "the placebo effect exists and is usable as a treatment" way, but in a "the placebo effect exists, and here is how it works in the body." That would be very interesting. Long ago I read a few papers on the placebo effect in regulating blood pressure via regulation of a certain chemical (it could have been a hormone like renin, but I can't recall). At the time, I thought the autonomic nervous system would be a good avenue to research to better figure this out (it would be a convenient explanation for how the placebo effect works: activating the nerves in the kidneys via the cross-talk from the central nervous system to excrete certain hormones). If it can affect the kidneys, what other bodily systems can it impact? The possibilities are not endless, but rather exciting. I believe the "placebo effect" is the reason chiropractors are so popular, in spite of there being no real physical evidence as to why their treatments help people.

LorenPechtel 3y ago
I do agree things should be studied but you have to be careful with it. Studies are big and expensive and things can be missed. Remember the big flap over hormone replacement therapy being shown harmful? Oops--all it really showed is what we knew all along, estrogen is risky for fat women.

bjornsing 3y ago

The main flaw in EBM is that it inverts the scientific method: It’s no longer about hypotheses and falsification. Instead it’s about “scientifically proven facts” (aka “evidence”). Sadly this aligns much better with our dogmatic instinctive understanding of knowledge as a set of agreed truths.

haldujai 3y ago
It's because medicine is as much an art as a science given the impossibility of problem space, also whenever we ignore evidence we end up harming/killing people.
deltaninenine 3y ago
It is true that in science nothing can be proven but this fact doesn't apply if you think in terms of statistics. Science is broad and doesn't always give answers in terms of a boolean falsification. You can be given a ratio as the result. This result is usually A probability established to a degree within the context of a sample size. This is the closest thing to proof that science can offer and we just go with it. EBM goes a bit further then just a probability in the context of a sample size. There's a further degree of rigor in the qualitative sense that the probability is causal and not correlative. It's subtle but causality is even closer to proof then a correlative study.

user3939382 3y ago

Good lecture on this topic https://youtu.be/z6IO2DZjOkY https://youtu.be/z6IO2DZjOkY

DoreenMichele 3y ago

Ah, the human as a specimen in a petri dish approach to so-called health care. Flies directly in the face of study after study after study that says: diet and lifestyle are major factors in all deadly diseases. Probably driven by modern tech, completely inadvertently, because x-ray machines and MRIs and such demand that the patient go to the clinic or hospital rather than the doctor going to the patient's home. Star Trek's Dr. McCoy and his tricorder was a dream of tech that you could carry in the proverbial little black bag. We aren't there and have forgotten a lot of important principles in the process of pursuing shiny tech. But it's generally a bad idea to critique any of that. Gets one nothing but hatred.

dekhn 3y ago
I think this is a pretty thoughtless statement. Ashkenazi women often have genetic mutations that cause them to get breast cancer and the cancer prognosis is much worse than average. This cannot be addressed by diet or lifestyle. However, genomic sequencing detected common patterns that can be tested for, and with that information, women can make informed choices about treatment or other actions, ideally well before they ever have a malignant tumor. I won't disagree that we could do a lot better overall with large-scale changes in diet and lifestyle. But it still would leave a lot of people dying of heart disease and cancer as well as infectious diseases. Those x-ray machines and MRI machines make a huge difference for people with internal injuries as well. No amount of diet and lifestyle will heal a shattered bone.
- DoreenMichele 3y ago
  That's a wild misreading of my comment.
  - dekhn 3y ago
    All the comments I make on Hacker News are done in good faith and assume good will on the part of the person I'm replying to. If you really think I misread, please rewrite what you wrote; as far as I can tell, I read and interpreted it clearly. It's best if you come out and say things directly, while your statement's thesis isn't entirely clear, but I read it as: Flies directly in the face of study after study after study that says: diet and lifestyle are major factors in all deadly diseases. <- yes, this is true. However, it's not a useful statement when criticizing medicine based on technology. Even if everybody in the world had a "perfect" diet and lifestyle, it wouldn't address the majority of diseases at a very large scale. Probably driven by modern tech, completely inadvertently, because x-ray machines and MRIs and such demand that the patient go to the clinic or hospital rather than the doctor going to the patient's home. <- OK, not sure what to say about this other than, it's an unfair comparison; there's plenty of in-home care and in-home doctors can't resolve a wide range of issues at a person's house. It also brings risk to the doctor, as well as causing them to spend their day travelling around. Star Trek's Dr. McCoy and his tricorder was a dream of tech that you could carry in the proverbial little black bag. We aren't there and have forgotten a lot of important principles in the process of pursuing shiny tech. <- actually, doctors and medical researchers, for all that they pursue shiny tech, still mostly have a good appreciation for "important principles". For example, I watched my surgeon count the sponges that they took out of my spouse after surgery, to make sure they hadn't left any in (this was a surprisingly common problem with surgeries). They don't try to make a "sponge detector machine". That's just one example out of millions; if you've followed doctors on Rounds, you'll see that most of what they do isn't technology. But it's generally a bad idea to critique any of that. Gets one nothing but hatred. <- I explicitly wrote my comment to be friendly, fact-based, and make my thesis as clear as possible. If you're going around pointing out that "medical basics that we've known for a while matter", nobody is going to agree with you. But if you attack doctors/medical researchers the way you do, you instance cause people to interpret you as somebody to argue with.

sampo 3y ago

Here is a 2022 critique of the narrow-mindedness of Evidence Based Medicine, by an Oxford professor and the author of what is perhaps the most widely used textbook on Evidence Based Medicine: https://ebm.bmj.com/content/27/5/253 https://ebm.bmj.com/content/27/5/253

epgui 3y ago

I'm a biochemist with a medical background, and FWIW, I think this is a garbage article. Hardly even worth commenting on. =/