"Worshiping" Evidence-Based Medicine
Dr. Black: I have a more basic problem with evidence-based medicine. Maybe this is a little unusual for me to say. It's based on randomized clinical trials. If I'm anything, I'm a trialist, and I've done them. I recall that when I was doing bench science and working with a specific technique, the first thing I read in a paper about a subject that I was familiar with was the methods. If the methods were wrong, I didn't read the paper because I wasn't going to depend on it. I don't think we train our doctors to read inclusions and exclusions criteria in a clinical trial. If the patient that you're treating is not someone who would be in that trial, how relevant is that trial to your patient?
If you've watched enough shows that take place in courts, you know that if one attorney tries to introduce something else, the other one says "objection." What's the objection? It's not relevant. The judge then decides. So I have no trouble with evidence-based medicine. I have trouble with worshiping at the altar of evidence-based medicine.
Dr. Weber: I think that's a very fair point. The problem with evidence-based medicine, of course, is that you have evidence for certain groups of people under certain circumstances. What about everyone else? Let's go to hypertension for a moment -- just a quick deviation. All the clinical trials in hypertension that were authoritative with hard endpoints and had good methodologies tended to be based on people who were 55 years of age or older. Usually these people also had other events going on in addition to the hypertension: histories of cardiovascular disease, renal impairment, diabetes, and so forth. So if someone were to walk into my office and he is 45 years old, I'd have nothing to say about him. If I were strictly evidence-based, I'd say, "Go home and come back when you're 55 years old because I don't have a clinical trial to guide me about you."
Dr. Black: "Get sick in the meantime because we can't prevent what you're doing."
Dr. Weber: That's the insanity of worshiping at the altar of evidence-based medicine, because what people have done is seen the absence of evidence. Not evidence to the contrary, just the absence of even testing an area and then using that as negative information and saying that you shouldn't treat.
Dr. Black: That's exactly right. The absence of evidence isn't the evidence of absence. That's a very important point for people to remember. Another thing they also say is that this is going to make it easier for doctors and patients. I'm not so sure that that is true. We're pretty good at aiming for a goal, and we know the goal when you are talking about a continuous variable like cholesterol or blood pressure. The categorization of being prehypertensive or stage 1 or stage 2 is artificial. In some ways it's silly, because there's not that much difference between 139 mm Hg and 141 mm Hg except that suddenly you're hypertensive as opposed to not being hypertensive. I think it may be the best we can do, but we have to be very careful about what we do with it.