MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

The most widely used definition of EVIDENCE-BASED MEDICINE (EBM) is probably this one: The judicious use of the best current available scientific research in making decisions about the care of patients. Evidence-based medicine (EBM) is intended to integrate clinical expertise with the research evidence and patient values.

David Sackett’s own definition is a little different: Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

Even though the principles of EBM are now widely accepted, there are those who point out that EBM has its limitations. The major criticisms of EBM relate to five themes: reliance on empiricism, narrow definition of evidence, lack of evidence of efficacy, limited usefulness for individual patients, and threats to the autonomy of the doctor/patient relationship.

Advocates of alternative medicine have been particularly vocal in pointing out that EBM is not really applicable to their area. However, as their arguments were less than convincing, a new strategy for dealing with EBM seemed necessary. Some proponents of alternative medicine therefore are now trying to hoist EBM-advocates by their own petard.

In doing so they refer directly to the definitions of EBM and argue that EBM has to fulfil at least three criteria: 1) external best evidence, 2) clinical expertise and 3) patient values or preferences.

Using this argument, they thrive to demonstrate that almost everything in alternative medicine is evidence-based. Let me explain this with two deliberately extreme examples.

CRYSTAL THERAPY FOR CURING CANCER

There is, of course, not a jot of evidence for this. But there may well be the opinion held by crystal therapist that some cancer patients respond to their treatment. Thus the ‘best’ available evidence is clearly positive, they argue. Certainly the clinical expertise of these crystal therapists is positive. So, if a cancer patient wants crystal therapy, all three preconditions are fulfilled and CRYSTAL THERAPY IS ENTIRELY EVIDENCE-BASED.

CHIROPRACTIC FOR ASTHMA

Even the most optimistic chiropractor would find it hard to deny that the best evidence does not demonstrate the effectiveness of chiropractic for asthma. But never mind, the clinical expertise of the chiropractor may well be positive. If the patient has a preference for chiropractic, at least two of the three conditions are fulfilled. Therefore – on balance – chiropractic for asthma is [fairly] evidence-based.

The ‘HOISTING ON THE PETARD OF EBM’-method is thus a perfect technique for turning the principles of EBM upside down. Its application leads us straight back into the dark ages of medicine when anything was legitimate as long as some charlatan could convince his patients to endure his quackery and pay for it – if necessary with his life.

2 Responses to The alchemists of alternative medicine – part 7 ‘hoisted on the petard’ of EBM

  • There’s something oddly appealing about the exception, so “random” recovery after alternative treatment appeals to the less scientific among us.

  • Prof. Ernst wrote: “Some proponents of alternative medicine…refer directly to the definitions of EBM and argue that EBM has to fulfil at least three criteria: 1) external best evidence, 2) clinical expertise and 3) patient values or preferences. Using this argument, they thrive to demonstrate that almost everything in alternative medicine is evidence-based.”

    Sadly, even regulatory bodies are known to factor in their own prejudices. For example, the UK General Chiropractic Council (GCC) declares its interpretation of evidence-based *care* to be:

    QUOTE
    …clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners, including the individual chiropractor her/himself.

    This effectively allows “in my experience” and “the patient likes it” to be considered along with evidence, effectively negating the whole point of evidence-based medicine.

    Ref: http://www.sciencebasedmedicine.org/brief-note-the-chiropractic-subluxation-is-dead/

    Indeed, the GCC has confirmed that pseudoscience such as craniosacral therapy and applied kinesiology fall within its definition of evidence-based care:
    http://jdc325.wordpress.com/2009/06/09/incompetence-and-the-general-chiropractic-council/

    IMO, it’s an abuse of trust of the patients the GCC is charged to protect.

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