eminence-based medicine -vs- evidence-based medicine

EMINENCE-BASED OR EVIDENCE-BASED…..
WHICH TYPE OF MEDICINE IS BETTER?

Eminence-Based Medicine

“In a letter to Bishop Mandell Creighton in 1887, Lord Acton penned the oft-cited expression, “Power tends to corrupt, and absolute power corrupts absolutely.” Nowhere has this principle been more evident in our health care system than in our failure to displace the status quo – denying patients greater satisfaction, better outcomes and cost savings. It boggles the mind to realize that there are concrete examples where compelling evidence exists to admit alternatives to the health care marketplace, yet patients are often neither empowered with nor aware of the possible effectiveness of these alternatives. Effective and economical delivery systems of health care are denied access despite inferior and costly performance by the gatekeepers.  Many accepted medical practices are in a constant state of flux, almost approaching fad status. That medical practices often seem to follow fashion rather than unassailable standards extensively documented in recent articles.”  Cherry picked from Anthony Rosner’s November 30, 2002 article in Dynamic Chiropractic (Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient)

“You have talked rather generously about evidence-based medicine. Most of medicine isn’t evidence-based. The overwhelming majority is more “eminence-based.   If you go to your doctor with lower back pain, there is a pretty good likelihood that you will get some imaging for that.  There are pretty good data that say that no subsequent decisions hinge on the observations made in that imaging, or that those decisions will happen at some incredibly low likelihood. But it goes much deeper than the instances of known waste. We do a lot of things, that are population-based when we fully know that 30%-40% of the people to whom we provide such therapies derive no benefit but experience all the costs and all the adverse consequences.”   Cherry-picked from Medscape’s Why Doctors Keep Doing Treatments that Don’t Work (BTW, the author is speaking of this sort of MEDICAL IMAGING here).

“And here’s Dr. David Barr in a JAMA article noting that errors may be regarded as the price that we, as responsible physicians, must pay for the inestimable benefits of modern diagnosis and therapy.  That article , entitled, “Hazards of Modern Diagnosis and Therapy­–The Price We Pay,” appeared in 1955. Like Dr. Barr, Drs. Samuels and Hadler seem confused about who, exactly, is paying what price. More broadly, their assertions exhibit little familiarity with the patient safety literature that has appeared throughout their own careers.”  From Dr. Michael Millenson’s October 19, 2015 article on The Health Care Blog (The Dangerous Patient Safety Delusions of Eminence-Based Medicine)

As you can see from the final quote above (1955), the more things change, the more they stay the same.  MIT graduate, Dr. Larry Husten, has been a medical journalist for the better part of two decades, and currently authors / edits the website CardioBrief; whose articles are routinely found on MedPage Today.  It was on MedPage that one of his recent posts caught my eye.  The article was called The Big Dirty Secret Every Doctor Knows: Eminence-Based Medicine is Not the Exception. It’s the Rule.   Husten mentions almost immediately that he has been writing a number of articles about Eminence-Based Medicine.  Huh?  I’ve heard of EVIDENCE-BASED MEDICINE, but what is Eminence-Based Medicine?

According to the (2012) archives of the COCHRANE REVIEW, Eminence-Based Medicine is, “Relying on the opinion of a medical specialist or other prominent health official when it comes to health matters, rather than relying on a careful assessment of relevant research evidence.”  What’s the old saying?  Opinions are like…..  Anyway, the examples that Cochrane gave were suspiciously familiar to examples I’ve been hollering about since I started practice back in early 1992 —- STATIN  DRUGS, FLU VACCINES, and MEDICAL TESTS / ROUTINE EXAMINATIONS.  The article ended with this paragraph.

“A recent study from US Public Citizen found that, since 1991, there have been 239 legal settlements, totaling $30.2 billion in federal and state penalties, levied against US pharmaceutical companies. There’s a real laundry list of crimes, but defrauding the government, hiding drug safety information, and hawking drugs for purposes beyond which they are approved are the main ones. Drug companies have pledged to change, signed ‘corporate integrity agreements’ and indicated that they want to move on, promising a better future. We can be hopeful, but we also have to be realistic. Paying huge fines for illegal activity is one thing, but will they be still playing the eminence game? Will they continue to fund their own experts and do research that goes through a selective reporting of ‘the evidence’? Sadly, that’s probably going to be the case so you must immunize yourself by continuing to ask questions and questioning answers.”

Some of the things that Husten mentions in his article are the very things I have repeatedly warned you about.  They are the very things that create a medical system whose practice is separated from its research by a gap the size of the Grand Canyon (HERE).  Two that were mentioned above are the INVISIBLE AND ABANDONED STUDIES and HUGE FINES (fines that sound monstrous to the average person, but are minuscule as far as the pharmaceutical industry is concerned).  There are others — many others (HERE).  As long as the money continues to flow into BIG PHARMA’S coffers, fines that run into the billions of dollars are thought of as nothing more than the price of doing business.  Speaking of business, lets go back to what Husten says of the ‘business’ of cardiology research.

“most eminence-based medicine is dressed up in the guise of evidence-based medicine. The distinguished thought leader will provide a ceaseless barrage of statistics, of which he (or she, but usually he) will have an unparalleled mastery. At each step of the argument, the logic will appear flawless, even brilliant. But, in general, the entire purpose of the talk will be to “prove” the thought leader’s opinion, despite the complete lack of genuine reliable evidence, or to disprove the actual evidence that exists, because it fails to support that opinion.  But the responsibility for eminence-based medicine goes well beyond the elite coterie of experts. The real problem is the culture of medicine, which rewards the hubris of eminence and actively punishes or offers subtle disincentives to anyone who question this process.”

The “hubris” that Dr. Husten is speaking of here specifically had to do with a prominent cardiothoracic surgeon from Bern, Switzerland — Dr. Bernhard Meier — a doctor who has completely and openly rejected EBM.  He writes in a recent issue of the European Heart Journal that, “Collecting evidence in a randomized fashion, ideally with double-blind, double-dummy, and sham-controlled design, could well be overrated….. an uncontestedly laudable product of the last century.  Grotesquely misleading conclusions can emanate from poorly conceived or sloppily conducted randomized trials….  Currently, it is a declared holy grail but that may take bizarre shapes. Waiting for the results of randomized trials may preclude patients from an apparently good thing while the trials are ongoing.” 

In a recent article from his site called Interventional Cardiology and the Rejection of Science, Husten argues that, “Medicine has always existed somewhat uncomfortably in the dual worlds of science and belief. Beliefs derive from tradition or good ideas. Interventional cardiology is a field built on good ideas. But we tend to forget that the field is also littered with the corpses of good ideas that didn’t work and even caused harm.”  The point is this; despite the myriad of problems with MEDICAL RESEARCH, we shouldn’t have to throw the baby out with the bathwater.   But something definitely has to give.

When I wrote about various sorts of  “physical examinations” FOUR YEARS AGO, I said that the article I was reviewing would have the medical community up in arms; denying (and ignoring) the veracity of their own profession’s conclusions.  I was right (HERE).  While I certainly believe that corruptness and financial conflict of interest in EBM is a huge problem (HERE), it’s probably not insurmountable.  I say “probably” because just like in our government, the corruption is malignant, reaching to the very highest levels (HERE and HERE).  Truthfully, I’m not quite sure what it would take to be able to really trust medical research (HERE or HERE).

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