Evidence-based medicine specifically seeks evidence for treatments, recommendations, and practice guidelines. However, while the spirit of evidence-based medicine is to be based on ethical and scientifically rigorous research, in practice, it is often simply shortened to “Is there any evidence at all?”
America’s Frontline Doctors continue to recommend treatments that have been studied and determined not to work. These anti-vaccine activists threaten public health by continuing to spread misinformation. But, they claim that they are practicing evidence-based medicine. How can they claim that they are practicing within the current paradigm of evidence-based medicine if they are peddling misinformation?
Evidence-Based Medicine (EBM)
The idea of evidence-based medicine has been around since the 1980s, and the term was officially coined in the 1990s. It arose from the realization that medicine was highly dependent upon the individual specific physician and heavily influenced by pharmaceutical companies' marketing. Sackett’s original editorial defined EBM as
“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.”
While this was a well-intentioned step forward in the philosophy and practice of medicine, as is often the case, naïve researchers, bad actors, and ulterior motives have found a way to corrupt this standard of treatment. Given laws of large numbers and how they act, you can find evidence for just about anything. Since the shorthand and practice of evidence-based medicine is often “Is there any evidence at all,” the answer is often yes, regardless of scientific rigor or plausibility.
This is the large hole in EBM’s paradigm that has been exploited, as exemplified by America’s Frontline Doctors. You can find evidence that ivermectin and hydroxychloroquine are effective treatments and prevention for COVID-19. However, just because evidence exists does not make it good evidence or scientific fact.
Science-based Medicine (SBM)
The good news is we can tweak evidence-based medicine to plug the hole. SBM takes the best parts of evidence-based medicine and expounds upon them. Science-based medicine is
“the use of the best scientific evidence available, in the light of our cumulative scientific knowledge from all relevant disciplines, in evaluating health claims, practices, and products.”
SBM considers the scientific plausibility of a claim, practice, or product along with what is already known, blending them to assess the plausibility of claims. SBM considers replication, statistical noise, p-hacking, the use of controls, and methodology. Science-based medicine takes us from cherry-picking studies that constitute “evidence” to discounting poorly designed studies that cannot be replicated and may also be scientifically implausible. Add in the requirement of thoughtful review and consideration of methodologies and statistics, and science-based medicine goes from “there is evidence that hydroxychloroquine is an effective treatment for COVID-19” to “hydroxychloroquine and ivermectin don’t work against COVID-19.” That is the real difference between evidence-based medicine and science-based medicine.
New medical products, treatments, or practices need to be based on the best science available, the intended spirit of evidence-based medicine. Science—rigorous methodology, statistics, and careful consideration of what is already known about an area, is the only real way to assess claims. From an ethical standpoint, we must ensure that medicine and, indeed, all healthcare are based on the best science available. Evidence-based medicine was meant to protect us from charlatans, bad actors, the naïve, and unqualified. However, we have weakened evidence-based medicine without considering basic scientific principles, laws, and knowledge. It can be improved.
We’ve made advances in the direction of science-based medicine. Preregistration of clinical trials utilizing human participants was a great way to keep researchers honest about their methodology and statistics and prevent p-hacking. However, for science-based medicine to truly take effect, practitioners require additional training in understanding basic research methodologies, the advantages, and disadvantages of study designs, statistics, and critical thinking. Without teaching our providers how to consume research, claims, and recommendations critically, we simply allow inertia to be our driving force - a disservice to patients and providers.
Ethically, science-based medicine honors the patient’s implicit or explicit request for the best care available and helps them to make sense of overwhelming amounts of information. Especially in an era where disinformation circulates freely, science-based medicine is one of the best perspectives allowing us to sift through the myriad of claims and determine if they are even scientifically plausible. Science-based medicine raises the floor on the quality of evidence. It’s time we start using it.
The opinions express are those of the author and not her employer.