Is 'evidence-based medicine' a system in crisis?

flickety good point. I reacted very badly to HRT - it caused such breast pain that I would walk to work in the mornings with tears streaming down my cheeks. Encouraged by the doctor (who was trying to be helpful of course because of my menopausal symptoms) I persevered (and changed brands, dosage etc etc) until I realised exactly what it was, stopped taking it and the breast pain disappeared. Years later, when I was desperate I tried it again and within a day or two the breast pain was back.

Yet thousands and thousands of women take those drugs and have little or side effects and all the positives.

EBM absolutely has to be nuanced for the individual.

I heard an interview on the radio discussing how variably different individuals react to the same drugs for the same diagnosis and discussing how our genes as well as influencing the illnesses we are more likely than average to develop also influences how we respond to drugs.

Evidence based medicine is fine if you fall in the broad band of people who respond to any specific medication as expected, but there will always be a group of people who do not respond to any given medication as predicated but would respond to the medication that only helped a small group of people.

I say this with some feeling my reactions to medications can be very variable. I am allergic to penicillin. I over respond to some drugs, like steroids, and others have no effect on the condition they are supposed to remedy.

Good idea, jane. I might just do that.

Go Galen
Hope the arm's better soon (medicinal of course)

I shall give them my "very hard stare" over the top of my glasses. The judges say they think it's intimidating

Just rattle your pearls at them Galen!
That should do the trick!

Bags That was one of the points made in the article - that the gains made by interventions are increasingly marginal, and a gain may be statistically significant, but not clinically significant.

Perhaps you should print out the article and take it with you next time you consult your GP

So has my GP! We don't bother each other!

Though I'm going to have to go to the surgery tomorrow as this arm is an area of 2"x1" and weeping and lots of pus!
Don't need the quack, just some stuff from the nurse to do it with.

Probably have to wait a month for an appointment at our surgery. I'm going to just turn up and be an awkward old besom and insist on seeing nurse even if I have to make a scene!

Me neither. He got the message.

Not at all happy about the tendency to unnecessarily prescribe statins.

My GP suggested that he'd apply my current postcode to some epidemiological test to see if I needed to take statins. I said: "My postcode has been all over the place" (it has), the implication being that such an exercise was pointless in determining my risk factor for heart disease. He shut up.

He also suggested I take blood pressure lowering tablets. My BP is a little high but only borderline. I asked him what caused high BP. He said: "aging". He then said I ought to be low risk because I'd never smoked and am not overweight, but.... MrB pointed out that even a large increase in risk, say 50%, would still leave one a low risk if the risk was v low to start with. Quite.

Jane I'm with you. I don't like EBM because I believe in treating the patient not the disease. It's too rigid. Of course I like to see real proof that something works, but in this case the baby is often thrown out with the bath water. If the patient has no faith in product the odds are it won't be as effective. If they do and it makes them feel better regardless of evidence?
Isn't the idea to try and cure patients? Or is that the thrown out bath water?

now that I have read it , I can say that I thought it was an excellent and timely article, calling as it did for a return to patient-centred medicine. Nothing to do with alternative medicine or quackery, Elegran, more a plea for all options within mainstream medicine (including of course the option of doing nothing) to be properly considered, rather than a knee-jerk treatment plan being implemented in response to a computer algorithm.

The other aspect of EBM that was highlighted was the growing tendency to treat risk, rather than disease. The most obvious example being the prescription of statins to those considered at risk of cardiovascular disease, as well as those with clinical signs.

We need a real debate about the ethics of this type of medicine. Who is benefitting - patients, Big Pharma, or the government?

Thank you Gk for posting the link.

I thought she meant that going for innovative but untried medicine over evidence-based medicine was not good. That is my point - there are some really wierd therapies out there, (like DIY treatments to "burn off" your skin cancer, thus avoiding the cancer experts) There are people who will use the headline to justify their pet theory and miss out on something that does work.

Doctors and consultants should, of course, apply their own experience and their observations of the patient to their prescribing. But don't the good ones do that anyway? The ones who just go into automatic prescription mode will just continue to do as they always have done.

Excellent summing up Grannyknot

I'm confused. I thought Galen was saying she thought evidence-based medicine was the most stifling idea to good medicine that there has ever been, and that made her , but you seem to have thought the opposite Elegran.

I think I've lost the plot here (not for the first time).

elegran I don't think that this paper is leaning towards that at all, it is a UK based paper, nothing to do with the US. It is highlighting the risks when the mechanical implementation of evidence based medicine is followed to the letter - as opposed to as jane says "being treated by clinicians who review available evidence and then interpreted it in the light of their own observations about me, ie, exercised clinical judgement rather than following a recipe".

I think it's great when things are questioned. And I do think it is true that "big pharma" and what they are funding skews research. Ben Goldacre says so in his book "Bad Pharma" ...

The paper says makes the case for a return to real evidence based medicine:

- Makes the ethical care of the patient its top priority
- Demands individualised evidence in a format that clinicians and patients can understand
- Is characterised by expert judgment rather than mechanical rule following
- Shares decisions with patients through meaningful conversations
- Builds on a strong clinician-patient relationship and the human aspects of care
- Applies these principles at community level for evidence based public health.

Medicine should always be part art, part science, not so? This paper is simply questioning whether there is too much emphasis on the one over the other.

I am with Galen here. the internet is stuffed with sites saying, basically, that some peculiar substance will cure your cancer because the writer took it and has been in remission for a while.

Publicising this article will lead to even more of the "Don't trust experienced doctors who have spent years studying and even more years practising and reading up on the latest studies, because they are hidebound gold-diggers who would rather ignore what will cure you and prescribe procedures that make them lots of money while keeping you ill" mentality.

Most of that comes from the States where being ill is one of the biggest expensive disasters that can happen to you, but it is becoming more prevalent over here.

Galen what idea is stifling and made you - ?

As for very new drugs that have not yet got approval but were very early results show a possible therapeutic effect in what would be otherwise hopeless cases, there is a procedure that doctors can use so they are able to prescribe them without the usual more robust evidence being there

I heard the young woman been interviewed on the Today programme - what I found so interesting was this resulted from analysis of a large international data set. Perhaps it also helped that she was young and therefore perhaps came to the task with fewer pre- conceived ideas. However, on the general topic of evidence based medicine - it's like all ideas, subject to misuse and manipulation but of itself a valuable tool. Modern medicine is just so much more complex - individual clinicians cannot possibly have experience or knowledge of the whole plethora of developments that have taken place and guidelines ( not to be followed slavishly but used alongside professional experience) are necessary in modern medicine. If you actually read guidelines produced by NICE or the Royal Colleges, you will see that they involve many caveats and a whole hierarchy of evidence. There are many treatments that are in accepted common use today for which the ' only' evidence is that they work. They were established years ago without clinical trials etc and it would now not be feasible or ethical to challenge that. I have had chilling experience in both my professional and personal life of doctors who have not followed guidelines and kept up to date - one case I particularly remember was the prescribing of a drug for a young child - although the Paediatric BNF said it was not to be used, the doctors defence was that he was taught to prescribe it at medical school ( 30'years ago) and so he would keep on doing so!

I think it's the most stifling idea to good medicine that there has ever been. Very

We are very lucky with the consultant who is treating DH. Although he is bound to go through the protocol set out by the NHS he is willing to adapt it in ways that will suit DH's condition and quality of life and is happy to discuss things that I find on line while talking to other patients around the world. If he thinks something will not help he will give me sound reasons rather than just saying No.

There is an awful lot of snake oil out there though.

janeainsworth - I tend to agree with your posts. My husband had a favourite saying 'rules are for the guidance of the wise and the blind obedience of fools' - I have often found that to be true.

Is it in the best interests of governments or the pharmaceutical industry to be able to cure everything?

I agree gn, and really good news that you have posted Re cystic fibrosis.

That particular student is going to make a diiference to Medicine, they are already producing such good results and still a student. Their parents must be very proud and happy with them, as is the world!