Tuesday, May 19, 2009
How Far We've Come, and the Rhetoric of Evidence Based Policy
Just two short comments today.
I worry that "Comparative Effectiveness" or "CE" is going to be the next medical buzz word, just like "Evidence Based Medicine" or "EBM" has been the buzz word for a decade. "Evidence Based Medicine" is a term which makes about as much sense as "Sex-based intercourse"--Were we practicing based on zodiac signs before EBM came along? (By the way, I borrowed "sex based intercourse" after hearing a prominent chair of medicine say it--I don't know if he coined it, but I thought it was brilliant). Soon we'll have a generation of physicians who are CE experts to bump out the EBM experts.
Posted by John Pfaff on May 19, 2009 at 10:44 AM | Permalink
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Another interesting post.
Typically, and correct me if I'm wrong, what is often meant by EBM is randomized controlled trials (RCTs; of course it's not just that but...) and I want to say a few things about those and then, EBM in general (and not all my comments are meant as criticism of something you said here). First, I agree that not all forms of evidence are the same and, in addition, our standards of what counts for sufficient or compelling evidence may differ according to the experimental or research context.
About RCTs, I think Rachel Cooper is correct in arguing that 1) RCTs can only be as good as the methods used to select subject populations, 2) that RCTs can only be as good as the methods used to judge success and 3) that RCTs are better suited to judging certain types of treatment than others. There are other, largely extrinsic (e.g., those having to do with specific social and economic conditions and imperatives of the sort identifed by the late John Ziman as particularly powerful in 'post-academic science) and ethical factors, that are also important in any discussion of RCTs, but I'll leave those aside.
EBM is one and very important factor in clinical judgment (as a species of practical reasoning, such judgment is rightly termed 'the je ne sai quoi of medical practice') but does not and should not invariably trump or determine such judgment (as analytical reasoning or deductive reasoning should not invariably trump or crowd out other forms of reasoning). As to the arguments why, please see, for example, Kathryn Montgomery's How Doctors Think: Clinical Judgment and the Practice of Medicine, 2006 (not to be confused with Jerome Groopman's book of the same name, which, while interesting, is not as important as Montgomery's).
And I think (and have argued in an upublished paper I hope to expand into a book) we should refrain from assuming the impossibility that anything valuable or meaningful from so-called alternative and complementary medicine with relevance to health and healing will be discovered in these medical doctrines and therapeutic modalities apart from that which survives the scientific scrutiny—the scientific sieve if you will—of EBM. There is a problem if we come to think that EBM is simply the de jure and de facto arbiter for what counts as medical truth, for what contributes to the health and well-being of the individual person. In other words, the rules and strictures of EBM are best thought of as regulative principles, epistemic norms, heuristics, maxims and such that are not absolute in character and reflect both the virtues AND shortcomings of a biomedical model of individual health and well-being.
Posted by: Patrick S. O'Donnell | May 19, 2009 2:15:16 PM
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