Okay, so we’ve discussed everything that’s right and good and, frankly, scientific about EBM: rigorous, double-blind, randomized, controlled trials published in reputable journals. What could possibly be wrong with that? Well, as Trisha Torrey points out in her About.com blog, quite a lot:
- The evidence is gathered using groups of people, not individuals.
- Not all patients have the same set of values.
- There may be built-in biases in the way the experiments are designed, too often based on a profit motive.
In addition, not every contingency can be covered. What if you’re dealing with a rare disease, one that hasn’t garnered sufficient attention to get a good deal of experimental data? Worst of all, as one recent case demonstrated, just because someone has a title or two after his name, that doesn’t mean he’s honest. In March of 2009, a Dr. Scott Reuben—the man Scientific American called the medical Madoff—finally came to justice, of a sort, after committing 13 years of fraud covering at least 21 medical papers of the 72 in which he had a hand (and, yes, there are still questions about the remaining 51 papers). The man even forged other doctors’ names on the fraudulent studies. So much for the much-touted reputable review process.
Now, ignoring that little reputation glitch for a moment, let’s consider two counterexamples in which EBM is of little or no use. In our second imaginary study, we’ll say a Mrs. Subject has stage IV cancer of the lilknown gland. To avoid confusion, we’ll use the same doctors’ names.
In example three, Dr. Maiweh, again unknown to Mrs. Subject, again strolls in unannounced, and explains to her that, “I’m afraid our tests show that you have severely advanced cancer of the lilknown gland. Your case is unusual, so I’m going to assume it’s not hopeless. Rather than giving up right away, I’m going to recommend we try an infusion of Luckizin. It’s no guarantee of any kind, but at this point it’s that or move you to a hospice. We’ll let you know when to expect to start the chemo.” Again, Dr. Maiweh appears unable to look at anything but the charts in his hands as he strolls on down the hallway to do his next good deed.
Example four: Dr. Onco, again having been introduced by Mrs. Subject’s PCP, gently informs Mrs. Subject the extent of her disease. She goes on to explain that, “All the existing studies, which don’t apply to you, offer little chance of survival beyond a few weeks. As I said, those studies don’t fit you. Previous subjects of lilknown organ cancer studies were twice your age, three times your weight, diabetic, and had a family history of Hodgkins. You don’t fit any of those profiles. So, we’re going to try the closest thing we have to an attack on cancers like yours. We’re going to try an infusion called Luckizin that’s been successful in similar organs and also tends to build up in the lilknown gland. Do you have any questions, Mrs. Subject? If not, I’m sure you will later. I’ll leave my card. Call any time.” Do I even need to mention that Dr. Onco knows to make eye contact, to shake hands, to smile when she hands over her card?
Example four shows what we want from a doctor when XBM trumps EBM. First, we don’t care how high a doctor thinks he or she is on the specialty’s food chain, we expect them to behave like human beings when they’re dealing with a delicate subject. We—most patients—know that studies have not been performed on every possible manifestation of any given disease. We know that our doctors are trained to take all of those important permutations into account and then apply their experience and their best judgment. This is why we pay those guys the big bucks. If all of medicine were no more than plugging in the right EBM answer for every available problem, doctors would require no more training than EMTs. In example three, again, Dr. Maiweh—despite apparently making a good choice—puts himself and his charts ahead of the patient and offers another fine example of a bad oncologist, working in what is possibly an undesirable hospital, and possibly referred by a PCP who hasn’t his patients’ best interests at heart.
As in example two in the previous post and four, above, if doctors would tell patients the whole rationale behind their treatment choices—whether EBM or XBM or a combination of the two—in most cases, the patients’ objections would disappear in a puff of logic.
As I said in my previous post, we want to know why our doctors are planning to do what to our bodies, and given that they’re our bodies, we want the information, the right, and the opportunity to say no.