The Problem Is in the Application: Pennie Marchetti, MD
Dr. Bernadine Healy, past director of the National Institutes of Health, recently made waves with an editorial in U.S. News and World Report that challenged the ascendance of evidence-based medicine (EBM). Quoting David Holmes, a Canadian nursing professor who specializes in postmodernist critiques of both nursing and medicine, she referred to EBM as "microfascism." That's a catchy phrase, suggestive as it is of totalitarian micromanagement of physician practices by the state. It's understandable that Dr. Healy would use it in an essay that warned about the dangers of limiting treatment options to generic standards, regardless of how well those standards suit individual patients.
However, the essay she alludes to, "Deconstructing the Evidence-Based Discourse in Health Sciences: Truth, Power, and Fascism," goes much further than that, suggesting that EBM is impossible because -- in true postmodernist fashion -- there is no such thing as an objective truth. Just as the postmodernist movement has given us moral relativism, so now we have scientific relativism.
This is hogwash. There is no room for relativism in medicine. The treatments that we recommend have real consequences, so we'd better be sure that they are effective -- or at the very least not harmful. That is the purpose of EBM: to base our treatment decisions on the best available science rather than on prevailing opinions or "expertise."
Medicine that is based on prevailing opinion results in things, such as double mastectomies for fibrocystic breast disease because a particular surgeon believes that lumpy breasts are a risk for breast cancer, hysterectomies for all postmenopausal women because a gynecologist believes that female reproductive organs past a certain age only serve to breed cancer, or surgery on every case of sciatica because a back surgeon says that that's the best approach.
I regret to say that I have seen all of these, always in a small town where one specialist's opinion sets the gold standard of care for his or her field simply because he or she is the only expert available. This is not good medicine by any measure, and yet, it was for the most part how medicine was practiced before the EBM movement became popular.
That's not to say that the application of EBM can't be abused; it can be. Evidence can be manipulated to make marginal benefits seem greater than they are, for instance. Most worrisome, however, is that by necessity, treatment studies focus on one treatment for one disease in a homogeneous population of patients of middling age. My patients are not homogeneous, nor do they have just 1 disease, and few of them are of middling age. Many of them are frail and elderly, with multiple medical problems necessitating the use of multiple interventions. There's no reason to expect them to respond to treatment as ideally as research subjects.
Therein lies the greatest problem with EBM: By using it as a standard to measure the quality of physicians, it runs the very real risk of shortchanging the health of patients.
Consider, for example, my patient Mr. T who has 3 diseases for which there are ample evidence-based standards of treatment: coronary artery disease, congestive heart failure, and chronic kidney disease. According to evidence-based measures of quality medical care, he should be on statins to slow the progression of his coronary artery disease, a beta blocker to maximize the treatment of his heart failure and coronary artery disease, and an angiotensin-converting enzyme (ACE) inhibitor to treat his heart failure and kidney disease.
Alas for Mr. T, he has had severe side effects to all of these. His statins made his muscles ache so much that he couldn't walk; his beta blocker lowered his blood pressure so much that he couldn't stand; and his ACE inhibitor raised his potassium so much that he was in danger of a deadly heart arrhythmia. From time to time, Mr. T has to be admitted to the hospital for an exacerbation of 1 or more of these chronic illnesses. Each time he's admitted, a consultant prescribes these 3 medications again with the same deleterious results, despite my diligent documentation of his prior reactions.
Why do they do that? Because the evidence-based treatment recommendations have become ingrained in their definition of good medical care. They are more concerned with meeting measurable guidelines for quality than with providing quality care.
That is where the real danger of evidence-based "microfascism" lies: not with the EBM itself, but with its misapplication.
Medscape Med Students. 2007;9(1) © 2007 Medscape
Cite this: Does "Evidence-Based Medicine" Diminish the Physician's Role? - Medscape - Jan 08, 2007.