Evidence Based Medicine vs Evidence Biased Medicine

The concept of EBM (Evidence Based Medicine) came into existence in 1990s to promote a systematic approach to helping clinicians in their practice to be guided by the best available scientific evidence. The philosophy of EBM encompasses five essential principles. First, it is grounded on basic health-care values (value-based medicine). Second, it requires scientific evidence. Third, it recognizes that the scientific evidence is complicated and usually limited. Fourth, it assumes that other factors like patients’ human rights, values, preferences and choices, are also important factors in medical decisions. Fifth, it argues that clinical expertise is an important component in medical decisions. Here, a pertinent question arises as to what is evidence and how we know, what proper evidence is. The majority of the large RCTs undertaken in clinical pharmacology are sponsored by the pharmaceutical industry with the aim to demonstrate to regulatory agencies the efficacy of investigated drug over placebo. Furthermore, negative studies are very rarely published. There is increasing competition for grants and jobs, the current mania for publishing papers and a disproportionate emphasis on quantity over quality in scientific outputs.

The seven key words of EBM and good science are: integrity, motivation, capacity, and understanding, knowledge, experience, and creativity. Without integrity motivation is dangerous, without motivation capacity is impotent, without capacity understanding is limited, without understanding knowledge is meaningless, without knowledge experience is blind, without experience creativity is impossible, without creativity there is no progress. EBM is here to stay integrating evidence-based practice and practice-based evidence. It is important to have in mind that EBM should be the integration of 1. Best research evidence (clinically relevant patient centered research), with 2. Clinical expertise (to identify unique health states and diagnosis, individual risks and benefits, as well as personal values and expectations) and 3. Patient values (unique preferences, concerns and expectations) which should be integrated into effective clinical decision.

The antithesis of EBM is practice based on pseudoscience, tradition, vogue, marketing and authority. Isaacs and Fitzgerald (1999) reported seven alternatives to EBM: eminence-based medicine, vehemence- based medicine, eloquence-based medicine, providence- based medicine, diffidence-based medicine, nervousness-based medicine, and confidence-based medicine. At recent times, biomedical science has become a vast and powerful industry and business producing a real jungle of information in ever increasing number of medical journals and other publications. However, in spite of the huge scientific progress, pseudoscience and     associated evidence biased medicine represent a serious threat to the concept of the EBM.

Pseudoscience is non-science, invalid or fake science posing as real science involving varied fads and fallacies in the name of science. Term pseudo- science also refers to a field, practice, or body of knowledge claimed to be consistent with the norms of scientific information processing and research, but in reality fails to meet these norms. In other words pseudoscience is characterized by production of irreproducible, incorrect or falsified results and non-useful research data. Pseudo- scientific article may seem to be scientific but actually violates the criteria of science and contain misrepresented, incorrect, untrue or falsified results and claims. Pseudoscience can be the product of misunderstanding and lack of education, fraud, and spin. Pseudoscience, fabrication, falsification, spin, and plagiarism are serious forms of scientific misbehavior that jeopardize the image of scientific journals and scientific community. Pseudoscience is like pornography: it is very hard to be defined, but one knows it, when he sees it.

Complementary Alternative Medicine (CAM) is evidence biased medicine and eminence based medicine. There are no RCT’S. An acceptable definition of an ‘alternative therapy’ would incorporate two key elements: (a) its efficacy is either unproven or disproved; and (b) the rationale for testing it in a trial cannot be expressed in acceptable scientific language. Publicity can function as a crucial factor against attempts to secure undeserved moral legitimacy in the domain of CAM.

It occupies a paradoxical position in modern medicine and healthcare: the plausibility and evidence base of many CAM treatments is very limited, and CAM approaches have been criticized and challenged by many scientists and physicians. This raises fundamental ethical question concerning the moral status of CAM. CAM is cheaper and less invasive than con- ventional medicine, that non-conventional modalities are desirable or preferable on the basis that they are ‘natural’ or ‘holistic’, and that patients’ autonomy is maximized by the provision of CAM to those who wish to receive it.

All clinicians have a professional ethical obligation to follow, understand and share the scientific evidence. However, many clinicians are confronted with the fact that the evidence that they learned in the Medical College has changed, often fundamentally. The medical students and doctors need to be familiar with different strategies of thinking and information processing and able to read between the lines. In spite of all difficulties, evidence-based medicine is here to stay to provide better quality and efficiency of health care and education in medicine.

Dr. A.K. Dewan
Director – Surgical Oncology