That the Heck is EBM?
Well it is Evidence-based medicine..Okay..So What’s That??
Almost 48 years ago when I began my medical training it was constantly drummed into my brain that we in medicine, were to always approach each and every individual patient as the unique and special human being that they were. As I started practice I remembered that…. ( and still do). Each and every patient that I saw was really different. Sure, many folks may have had diabetes or heart disease or cancer or even simple colds ,but all of these problems affected each and every person differently because people were/are different. It was always a good rule of thumb for me to remember that and remember that each patient needed to be approached and treated uniquely, differently and specially as the special person that they are.
Way back then I guess you could say we had what is now called evidence based medicine or EBM. At that time I started my still continuing practice of calling each patient after a few days just to make sure that they were better. My ulterior motive was I wanted to know if what I did for them helped to make them better or made them feel better. So, I was checking the evidence and I was basing my medical practice on what I did that worked.(my evidence) That was early EBM. Pretty much all the doctors that I trained with and later practiced with did the same thing. We didn’t know what EBM was back then , but I guess that’s what it was back in our early days of medical practice.. We would all treat folks and check back with them to make sure that what we did worked and was successful in making a difference, hopefully a good or improving difference for them.
Over the years EBM has been “bastardized”, and taken over by both organized medicine, big Pharma, insurance companies and other third parties. They have come up with their protocols and have tried their best to change medicine to one size fits all, ignoring the uniqueness of us all being individuals. In other words, medicine now believes that all people are pretty much exactly alike. Every person with diabetes needs to be treated the same way. Every cold needs to be treated the same way.
I guess we saw this in the past several years with Covid. I had many, many patients who got sick and went to area emergency rooms to be told that “you have Covid, come back when you can’t breathe”. I know this sounds harsh but I heard it so many times over the past it’s almost permanently stamped on my brain.
I see something similar now in that over the past several weeks I had numerous patients that went to emergency facilities in our area and were first of all told that they had the flu and then were sent home. They were not offered symptomatic relief or any advice other than “the flu is a virus and there’s nothing we do for viruses”. One recent patient was an 84-year-old patient of mine who gets really sick really quickly. He had not had anything to eat or drink for almost 2 days. He was so weak he could not walk but the protocol says that it’s a virus and “nothing works with viruses” and therefore was told him that they don’t do anything except diagnose it and send them home. This is what I mean by EBM. Sure there may not be a wonder drug that knocks out flu but there are many things that we as physicians and medical providers can do to comfort the sick. The first thing we need to do is recognize that they are individuals and treat them as such.
I really don’t want to get into it here but I think that’s part of the problem with the Covid 19 response. There were protocols handed down to hospitals and the hospitals were pretty much instructed not to vary from those protocols. There are a lot of bad things that came from that and the folks that wanted to treat patients as individuals and ignore the protocols and do what was best for their own personal patient’s were labeled as incompetent and marginalized in spite of their reputations as being some of the finest physicians in the world. Many of them are the most published physicians in the world and yet they bucked the system and were blackballed by their employers, professional societies, etc. I’ll get more into this in a later article but right now I want to stick to EBM
A great book came out years ago about EBM looking at its origins and its weaknesses. There’s been plenty of things written about the strengths, but this was the first really fair evaluation of how organized medicine, medical schools, insurers, and Big Pharma have changed EBM.
As I mentioned earlier, when I first started practicing medicine, I started with a habit that I have continued to the present day …..that is… I like for my office and myself to contact my patients, especially the really sick folks a day or two after their visit to see if what we have done and used has helped their problems. If we send to a specialist or a consultant, we check to see if the consultant was helpful. We try to see if the medication had side effects.We try to ease their symptoms using truly integrative medicine. We try to make sure they’re feeling better. This is the evidence-based medicine or EBM that I learned. EBM should not be about protocols but more about what has worked with each of our patients, in our individual practices. Sure I love to talk with colleagues to see what they are doing and what has helped with their patients having similar problems.
EBM and protocols have led modern medicine to become cookbook medicine. The sad thing is when patients don’t respond to the cookbook many providers this day and age don’t have any idea of what else to do. They merely throw their hands in the air and say there’s nothing else they have to offer or the punt the patient on to another provider.. Much the same as my patients with influenza over the past several weeks experienced in emergency/urgent facilities. They weren’t offered anything for their symptoms. They weren’t offered anything to help ease their discomfort. I can’t really blame the providers, because medicine now is to the point that if you vary from the protocol then you may suffer as a provider serious consequences from your employer or the insurer or medical authorities, or all of the above.
The book that I mentioned that really talks about the history of EBM is “Tarnished Gold: The Sickness of Evidence-Based Medicine by Steve Hickey, and Hilary Roberts.” In that book they talk about the history and evolution-changes of EBM.
They say “Evidence-based medicine, the "gold standard" of medical decision making, is increasingly unpopular with clinicians. They are right to have reservations. EBM breaks the laws of so many disciplines that it cannot be considered scientific or even rational. Decision science and cybernetics show the disturbing consequences of such flaws. EBM fosters marginally effective treatments, based on population averages rather than individual need. Its mega-trials are theoretically incapable of finding the causes of disease yet swallow up research funds. Ultimately, EBM cannot avoid risking patients' health. It is time for medical practitioners to discard EBM's tarnished gold standard, reclaim their clinical autonomy, and provide individualized treatments to patients. This book explains why and how.”
EBM is what led to all providers being instructed years ago to treat our patients with pain….to treat pain as the newest vital sign…along with blood pressure, temperature, etc. Then it was EBM years later that led to doctors being punished for TREATING pain. Doctors were told that 5 days of meds was enough. The opiate crisis (which has been blamed in legal cases on a few BigPharma companies) suddenly meant that patients with longstanding chronic pain were to be now treated according to protocols that limited meds, combination of meds, etc. We were told EBM told us how many “morphine equivalents “ was enough for our patients and we could be in big trouble if we varied from that by addressing the individual patients needs.
Recently we have heard a lot about repurposed drugs. A 2018 article in NATURE magazine said- “Given the high attrition rates, substantial costs and slow pace of new drug discovery and development, repurposing of 'old' drugs to treat both common and rare diseases is increasingly becoming an attractive proposition because it involves the use of de-risked compounds, with potentially lower overall development costs and shorter development timelines. Various data-driven and experimental approaches have been suggested for the identification of repurposable drug candidates..”
There are literally hundreds of repurposed drugs. These include aspirin. Originally used for inflammation and pain, repurposed as anti-platelet medication. Methotrexate was used for cancer, now for psoriasis and rheumatoid arthritis. Finesteride was used for prostate enlargement and now for hair loss. Even Viagra..originally meant for angina, is now used for erectile dysfunction and pulmonary hypertension. Gabapentin was meant for seizures, but now it is used for neuropathy and pain. I could go on and on. Why the changes…well some doctor or researcher said..lets try it and their trial, or their evidence, showed promise…so the medical community embraced it . THIS is true EBM as it was meant to be. This repurposing came to a screeching halt though in the past 3 years as I have seen doctors punished now for using somethings that science has lauded, even things that have won Nobel prizes, and suddenly repurposing of some drugs is NOT okay, even though some folks have seen success with their use. Why?
So EBM has changed. My EBM and that of other doc’s is no longer ok, but the published protocols by the groups I mentioned above, are okay. Confusing isn’t it.
We physicians and medical providers need to remember the oath we took to help our patients and “first do no harm”. I believe it is harmful to our patients to NOT treat them as individuals and to address their individual needs. I encourage you to read the book “Tarnished Gold” and better understand the system by which many of you are now treated.