sorry, I should learn to read

I think it’s both and I think antirealist was referring to practice.

For instance, an EBM approach to dealing with anxiety in a clinical setting (ie a patient presenting with anxiety) is to rely on approaches which have been tested and shown to be effective. Psychoanalysis, for instance, does not qualify whereas cognitive-behavioural therapy (CBT) does.

[OB: "This discussion, on the other hand, I think is a good one. Funny how these things vary!" Different strokes for different folks! 8-)]

http://www.telegraph.co.uk/health/main.jhtml?xml=/health/2006/08/07/nhospital05.xml

Another thing I’m not clear about: does EBM refer to clinical practice, or to medical research? I was assuming it referred to research, but antirealist seems to be saying it refers to practice. Is that accurate, or just fancy footwork? Antirealist, are you being tricky there?

RCTs are best for testing the efficacy of possible large-scale interventions (eg HRT or use of blood pressure medications such as statins).

They are impractical or impossible in other circumstances. That, however, doesn’t mean that EBM can’t be done.

“EBM practitioners often seem to be operating with realist background assumptions – that there is a correct answer to the question, and RCTs can provide it. This is (or ought to be) Holmes’ point. Maybe you don’t have much in common with the population studied in the RCT. Maybe you appear to have a lot in common, but you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug.”

Aren’t there realist background assumptions in those last two hypotheticals too? Isn’t “you don’t have much in common with the population” a “correct answer to the question” “do you have much in common with the population?” Isn’t “you appear to have a lot in common, but you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug” a correct answer to the question “do you appear to have a lot in common, while you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug?”

Antirealist, aren’t you just saying sometimes answers are more complex than researchers (at first) realize, rather than that there are no correct answers? Or aren’t you. Note: I think there’s a correct answer to that question, but I don’t know what it is.

http://www.biomedcentral.com/1472-6963/3/14

There’s a heading toward the middle of the article.

“Maybe you appear to have a lot in common, but you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug. Maybe you don’t, but you’re 35 years old with 3 kids and wonderdrug is your last hope. How does the RCT help you, your physician, and the people paying for your treatment decide what is best in your case?”

It depends on that “unknown to”. All we can ever do in any particular case is apply everything we know. So if it is a yet to be discovered fact that some people can have a biologically -determined predisposition to respond favourably to the drug, all we are left to work with are probabilities. And we know how to play them.

Think about it this way: suppose a process can have two results, one of which occurs 70% of the time (call it A), the other 30% (call it B). Suppose there is nothing known or knowable that allows you to distinguish, before an individual run of the process, between initial circumstances that are more likely to lead to one or other result than the 70/30 that is known anyway. What strategy of guessing the result will give the best rate of success in the long run? Answer: 100% of the time plump A. You will be correct 70% of the time and in the long run you cannot beat that.

Sometimes people think “the probabilities do not apply to me”. Unfortunately they always do.

Robyn Dawes wrote a great book on this subject, as it relates to psychology, “House of Cards” (http://www.amazon.co.uk/gp/product/0684830914/202-3874616-2459807). He is particularly scathing on psychologists who claim that their clinical experience can override the sort of probabilistic reasoning I outlined above – because psychologists have shown that clinical outcomes do not improve with clinical experience.

As Damon Runyan wrote, “The race is not always to the swift, nor the battle to the strong, but that’s the way to bet.”

http://en.wikipedia.org/wiki/Evidence_based_medicine

Of course as a lay-person I had sorta assumed that medicine was already science-based, at least in the sense that, for example. the medicine my doctor prescribes has been tested to determine if it really will help get rid of X condition. So I am obviously not getting the nuances or even the basics of EBM.

But I found Holmes’ _political_ criticism so strange that it has piqued my interest in the subject.

•••

As to your desire for more links, OB, I would like to point out that while we are not Palm Springs, we do have some very nice ones in and around Seattle. Maybe B&W could sponsor a tournament next year?

Google “EBM criticism” and see:

Not a fan of wiki, but…

http://en.wikipedia.org/wiki/Evidence-based_medicine

and…

http://www.biomedcentral.com/1472-6963/3/14

and…

http://www.cebm.net/ebm_is_isnt.asp

The real debate (I think) hinges on how consider EBM, and its alternatives, are defined.

My GP (and her practice) do EBM but the notion that this ignores individual characteristics is laughable.

Links! I want links!

It tells your physician that, if you match the population studied in the RCT, you have a 5% chance of responding.

This is considerably better than a non-EBM approach where there is ABSOLUTELY NO WAY of making any such predictions.

“To give an example, there is a tendency in the EBM world to treat RCTs as if they represented a kind of epistemological gold standard (even though they may say they don’t, they do, which is why I say examine their methodology carefully). “

That would be because RCTs ARE the gold standard for testing hypotheses about medical treatments.

The situations in which they can be applied, however, are very, very limited.

The evidence in favour of EBM is so widespread and pervasive that I have trouble seeing how anyone can rationally challenge it.

“There are indeed powerful political and institutional interests backing EBM.”

So what?

This is simply an “ad hominem” attack and of no value whatsoever.

“Critics of EBM typically dispute EBM’s notion of what constitutes evidence, not the need for evidence in medical decision-making.”

Provide an example to support this statement.

“Clinical medicine is not a science. It is a practical discipline which deals with individuals. It utilizes techniques developed by, and discoveries made by science, but it is not itself a science.”

So what?

The same could be said for engineering or (practical) psychology (as opposed to research psychology).

When I go to see a doctor I am certainly an individual and I expect the doctor to take my individual characteristics (eg allergies) into account when diagnosing and treating my condition. I FAIL to see why this creates any problems for EMB.

antirealist, you make considerable reference to criticisms which could be made, but don’t actually make any!

“How can metaphysical life theories and explanations taken seriously by millions be ignored or excluded by a small group of powerful people called ‘scientists’?”

That’s pretty much what that article is saying – note the word ‘excluded.’ This is classic stuff.

(Good luck with the grip, David!)

In fact what I read Holmes as saying is that _any_ body of expertise — say the collective wisdom of golf pros on how to grip the golf club (yes, such issue weighs heavily on me these days) — is suspect because it leads to “privileging” one view over another. Ugh.

On the other hand, antirealist has set me straight; I didn’t know about these non-absurd critiques of EBM, and clearly ought to before I mouth off.

Like OB, when I first read the paper by Holmes et al., I thought it was a Sokal-style hoax – hence the quotations. Well apparently it isn’t a hoax, and so I assume they are trying to make a serious point. Now it’s true that if you grit your teeth, re-read the article carefully and try hard, you can (sort of) see what they’re trying to get at, and I don’t disagree with your interpretation. Indeed, your comments do a good job at distilling down the essence of their argument. But for goodness sake, why didn’t they make their case with similar clarity instead of this pretentious and absurdly balletic prose style? A prose style incidentally, that was so ruthlessly parodied by Sokal.

The Sokal hoax is spoofing people who dispute a realist approach to the physical sciences.

The Holmes et al piece is attacking those who (as they see it) want to treat the practice of clinical medicine as if it were one of the physical sciences, with the same realist implications.

Despite the similarity in language, I don’t think these two excerpts you’ve provided have anything in common. What pisses me off about Holmes et al is that it might lead some people to think that a critique of EBM amounts to a critique of the scientific method à la Sokal, and that’s nonsense.

Clinical medicine is not a science. It is a practical discipline which deals with individuals. It utilizes techniques developed by, and discoveries made by science, but it is not itself a science.

To give an example, there is a tendency in the EBM world to treat RCTs as if they represented a kind of epistemological gold standard (even though they may say they don’t, they do, which is why I say examine their methodology carefully). But if an RCT shows that only 5% of patients with X respond to wonderdrug, and you have X, what does that tell your physician about the probability you will respond to wonderdrug? EBM practitioners often seem to be operating with realist background assumptions – that there is a correct answer to the question, and RCTs can provide it. This is (or ought to be) Holmes’ point. Maybe you don’t have much in common with the population studied in the RCT. Maybe you appear to have a lot in common, but you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug. Maybe you don’t, but you’re 35 years old with 3 kids and wonderdrug is your last hope. How does the RCT help you, your physician, and the people paying for your treatment decide what is best in your case?

There are indeed powerful political and institutional interests backing EBM. And to the extent that OB can jokingly say something like “The only liberatory and truly fair thing to do is to have evidence-free health science” does show that EBM, apparently just by virtue of its name, really has gained a privileged status. Critics of EBM typically dispute EBM’s notion of what constitutes evidence, not the need for evidence in medical decision-making.

“There are many natural scientists, and especially physicists, who continue to reject the notion that the disciplines concerned with social and cultural criticism can have anything to contribute, except perhaps peripherally, to their research…………Rather, they cling to the dogma imposed by the long post-Enlightenment hegemony over the Western intellectual outlook, which can be summarized briefly as follows: that there exists an external world, whose properties are independent of any individual human being and indeed of humanity as a whole; that these properties are encoded in “eternal” physical laws; and that human beings can obtain reliable, albeit imperfect and tentative, knowledge of these laws by hewing to the “objective” procedures and epistemological strictures prescribed by the (so-called) scientific method.”

Alan D. Sokal: “Transgressing the Boundaries: Towards a Transformative Hermeneutics of Quantum Gravity.”

“Those who are wedded to the idea of ‘evidence’ in the health sciences maintain what is essentially a Newtonian, mechanistic world view: they tend to believe that reality is objective, which is to say that it exists, ‘out there’, absolutely independent of the human observer, and of the observer’s intentions and observations. They fondly point to ‘facts’, while they are forced to dismiss ‘values’ as somehow unscientific. For them, this reality (an ensemble of facts) corresponds to an objectively real and mechanical world. But this form of empiricism, we would argue, fetishises the object at the expense of the human subject, for whom this world has a vital significance and meaning in the first place. An evidence-based, empirical world view is dangerously reductive insofar as it negates the personal and interpersonal significance and meaning of a world that is first and foremost a relational world, and not a fixed set of objects, partes extra partes.”

Dave Holmes et al., “Deconstructing the evidence-based discourse in health sciences: truth, power and fascism”

The idea that EBM is becoming an “exclusionary and dangerously normative” mindset is actually not that unusual among medical researchers, and to some extent the authors have a valid point. But they underestimate the extent to which EBM is controversial within medicine itself. And rather than attacking EBM on scientific grounds, using specific examples, the authors prefer to float in a sphere of abstraction, where just invoking the names of Deleuze, Guattari, Derrida, Lyotard and Foucault appears to constitute some kind of argument. Unfortunately Foucault was a far superior thinker to most people who cite him as an authority.

There is a critique to be made of EBM and its institutional and political influence, but this sophomoric paper isn’t it.