By Clive Lindley-Jones | May 2, 2012 12:02 pm
Medicine is for people, not statistics: What is the Evidence for Evidence-Based Medicine?
At this time when we are again remembering the Bard of Stratford it is interesting to hear that in his day the only way most people gained their news and /or history was either through a conducted tour around the graves of the kings in Westminster Abbey or through the new-fangled history plays being put on by the likes of Shakespeare. Evidence and the need for accuracy has come on a long way since then! We humans can never fully agree for long on anything, and while there has been a healthy drive for more accurate evidence based information, not only in history, but more especially in medicine, all is still not happy and free from controversy in this area (as I noted in my piece in March: see March blog here.
Following this, I was interested to read two cogent critiques of the prevailing Evidence-Based Medicine (EBM) orthodoxy. One of which read here emphasizes the exclusive power of Evidence Based Medicine. As they clearly and convincingly state, medicine is for people, not statistics. In some circles even to criticise some of the weaknesses of Evidence Based Medicine is tantamount to labelling yourself beyond the scientific pale. Sadly, this will not do. We must keep tweaking the new orthodoxy and pushing it, better to reflect the facts as they appear to us both through the rigours of statistical analysis and in our clinical experience. EBM has lots to offer, but is not yet the perfect means for all our understanding and guidance, in what is best for our patients.
While statistics can serve us well, to base the whole of clinical medicine so exclusively, slavishly on large scale statistical analysis is hard for front line clinicians, who actually touch their patients. Not because we don’t want to use the mighty power of science to avoid all the pitfalls of our own distorting clinical pride and desire to help, but rather, because experience tells us, as we touch and learn from our patients, decade after decade, that each patient is different and individuals are different each time one sees them.
To over depend on huge, hard to duplicate studies, useful as they can undoubtedly be, is to lock ourselves in to too rigid and limiting a model. And if you think I am grumbling, read this absurd report from a Nottingham NHS trust that has banned physiotherapists from touching their patients. As stupid and unscientific decisions like these are perpetuated by bean counters, patients suffer and are driven out of the NHS to seek proper care from experts like osteopaths, who sadly are only employed by a few NHS Trusts, perhaps just because we touch our patients. Click here to read the Telegraph article Physiotherapists banned from touching patients .
Let us also save money by banning psychologists from talking to their patients and surgeons from touching or cutting theirs. So much money could be saved this way! On that let us hear from Hickey and Roberts as they wind up their paper:
"Diagnosing medical conditions is challenging, because we are each biochemically individual. As explained by an originator of this concept, nutritional pioneer Dr. Roger Williams, "Nutrition is for real people. Statistical humans are of little interest." Doctors must encompass enough knowledge and therapeutic variety to match the biological diversity within their population of patients. The process of classifying a particular person's symptoms requires a different kind of statistics (Bayesian), as well as pattern recognition. These have the ability to deal with individual uniqueness.
The basic approach of medicine must be to treat patients as unique individuals, with distinct problems. This extends to biochemistry and genetics. (And we osteopaths would also say strongly, to bio-mechanics as well) An effective and scientific form of medicine would apply pattern recognition, rather than regular statistics. It would thus meet the requirements of being a good regulator; in other words, it would be an effective approach to the prevention and treatment of disease. It would also avoid traps, such as the ecological fallacy.
Personalized, ecological, and nutritional (orthomolecular) medicines are converging on a truly scientific approach. We are entering a new understanding of medical science, according to which the holistic approach is directly supported by systems science. Orthomolecular medicine, far from being marginalized as "alternative," may soon become recognized as the ultimate rational medical methodology. That is more than can be said for EBM".
In the second piece on this them, Stevej blogs that;
"Medical Science uses RCT's because it's the best thing they've got, but belief in them "should be held lightly", they are not infallible nor free of serious deficiencies.
Evidence Based Medicine is a good servant and a poor Master. The emphasis must be on Medicine, not 'Evidence', on providing good patient care and outcomes. Chief of which is focussing on Patient Safety, not the glittering bauble of "efficacy". "First, do NO harm"...
You can read the whole interesting and well argued piece here.
Following last month's piece on some of the problems with our present meat based diet and the pressures on farmers to keep up production of meat to feed this over focus on meat, I noticed this report from The Soil Association on the increased risks of E coli infections that stems from the routine use of antibiotics in intensive meat production. Helen Browning, chief executive of The Soil Association says in her preface to the impressive report:
"Antibiotics have revolutionised modern medicine and saved millions of lives; there are times when we have all been grateful for them to restore our own health, or that of loved ones. But problems can emerge with their over-use. One of the major concerns to emerge in connection with such over-use is new E.coli and MRSA superbugs on farms. Most public health experts are agreed that resistant bacteria are created in food animals by antibiotic use and that some of these are being transmitted to people".
Book of the month
Dangerous Grains: Why Gluten Cereal Grains may be Hazardous to Your Health
By James Braly,M.D. and Ron Hoggan,M.A.
This is an interesting and helpful book, now ten years old and therefore, in this fast moving world, somewhat dated, but well worth the effort to study. It explains the benefits of a gluten-free diet in relieving and preventing the ailments associated with celiac disease, gluten sensitivity, and more than two hundred chronic illnesses and autoimmune conditions. Starting by showing how we have only been eating grains for, less than 2% of man’s time on earth, and only eating the new, intensive gluten grains so prized by bread manufacturers in the very recent past. It becomes clearer why so many hidden illnesses may have a link to gluten, and not only diseases of the digestive tract. Anyone with a difficult to diagnose chronic illness should at least consider the possibility of gluten being a part of the picture. It may not be, but it is not always easy to rule it out and this science based book outlines the complex story of man’s often unhappy relation to gluten. As they point out, bread makes up more than half of the total calories in the average diet of many peoples in western countries and grains represent more than one-third of all food crops grown world-wide. Yet the protein contained in various breads grains, gluten, contributes to long-term illness for millions of people.
I have attended some very interesting and insightful lectures by Dr. James Braly who has long been an expert on issues such as allergy, intolerance, food and health. Here Braly & Hoggan, both gluten sensitive, go beyond the old, more limited ideas, traditional associated with celiac disease and gluten sensitivity, widening our understanding to the role gluten in wheat, rye, barely, spelt, kamut, tricicale and other grains can have in a range of conditions - cancer, autoimmune disease, osteoporosis, and intestinal disease, amongst others.
I certainly had never realised the extent of the damaging effect gluten could have on those who are effected by it nor the numbers of people involved. Did you know, for example, that depression has been claimed as the most common symptom of celiac disease, or that about 70% of children with untreated celiac disease show exactly the same abnormalities in brain-wave patterns as those who have been diagnosed with attention deficit disorders?
As Braly & Hoggan point out;
“The whole area of research into gluten-sensitivity is fraught with difficulties, punctuated by interminable delays and innocent errors stacked on top of lingering misconceptions.”
The book needs to be supplemented by more modern searches on-line, and very soon some much more effective and easier to administer tests will be available in Europe to more accurately test for the possibility of gluten playing a role in a number of previously believed to be unrelated diseases. however this book still gives a good coverage of the role of gluten in ill health for many who may be completely unaware of its role.
Tell me what you want!
In new experimentation with blog widgets there is a short poll asking you to tell me what topics you would like to see covered in future Health-E Coaching posts! If you have a moment do give it a try.