Wednesday, November 20, 2013

The Alternative View of Evidence Based Medicine

In the US, Evidence Based Medicine has been stupidly and ignorantly introduced through the HMOs for simple cost cutting. What I always hear and read from American doctors is 'The HMO says No!' and that is the end of the conversation, leaving the doctor standing in front of the patient humiliated and disempowered. 

In other parts of the world, its introdruction has been driven and managed by the medical profession and things are very different. The answer is not a blunt 'No!'. The response is 'What is the problem? Well, this is the best treatment for that diagnosis on offer for the patient's short and long term health.' 

A highly ethical medical profession that cares about the health of their patients created and introduced this system. It comes from a system that traditionally fostered good patient health and pioneered preventative medicine and true healthcare. Doctors were not paid by the consultation. They were paid a salary for taking on a responsibility for a community whether working in hospital or family medicine. It was in their interests to keep patients healthy and prevent them from needing and seeking medical attention. The sicker their community was, the more work they did for the same amount of money. The ideal was to get and keep their patients as well as possible through lifestyle, self-care and education.

Some of the earliest and most profound results of Evidence Based Medicine were about lifestyle and exercise which the medical profession had largely been leaving to the patient's common sense. The big turn-around for common sense was the danger of bedrest and exercise avoidance.

A significant number of accepted therapies were reinvestigated to see if the evidence proved them as effective as doctors thought they were. There were surprises. Some drugs were being used on faith, tradition and wishful thinking focused around the shared expectation of the doctor and patient that the doctor must be able to do something. 

This came down to bad science, science that broke it founding principles. The Noble Scientific Ethic of Objectivity had been betrayed. Emotions and vested interests were getting in the way of truth. Scientific theories from the laboratory were being applied in the complexities of real life. Simple facts were being forgotten, most notably that the human body attempts to compensate for anything externally done to it. Sometimes it was enough to cancel out the effect of the drug entirely until unusably toxic levels were reached. (The Therapeutic Window)

Theories of science did not necessary work in real life. They were just being accepted by the doctors and patients because of a false belief in the certainty of science and technology. Theories were being built on theories, names and academic reputation and not evidence that the treatment actually worked in real life. Convoluted arguments were being constructed in theory that proved real life black to be white.

The reverse was also happening. Therapies that did produce real life benefit were being overlooked or even attacked because they had no scientific basis or mechanism behind them. They were being discredited by the medical profession and through it, scientific and technological medicine were gaining a monopoly and strangehold on health.

This earlier medical culture, called Theoretically Based Medicine, was open to conscious and unwitting abuse. It was not good for the health of the patients but great for the power, popularity and pockets of the medical profession.

Any of the criticisms against medicine, even by the conspiracy theorists, only applied to Theoretically Based Medicine. All ethical matters and criticisms have been systematically resolved in the new culture of Evidence Based Medicine. In fact, others in health and 'healing' have been left behind practicing just the way that doctors did before revitalising their ethical standards. 

The best of this new medical culture welcomes other therapies is its complex holistic treatment plans. They call such therapies complimentary therapies. It is the competitive 'healers' who aggressivelycall  themselves alternatives and few are prepared to work in any sort of team. Rather than trying to cooperate with the medical profession, many would prefer to decry and discredit it. They certainly will not work in teams with doctors for the sake of patient health in my experience.

Evidence Based Medicine has actually created a (nearly) fair playing field for modern medicine and its alternatives. They are assessed on an equal basis for their proven risk/benefit profile regardless of whether scientists understand or like their theoretical basis. Particularly when it comes to side-effect profiles, the alternative therapies often win for the first line therapy of non-life threatening conditions.

It is a theoretically fair playing field. Alternative medicine faces the costs and organisation to produce high quality clinical trials that are far from its individualist and competitive culture. Modern medicine has opened the door but the onus is on them to come in.

One of the first successes was the use of visualisation of the immune system fighting back in childhood leukaemia. Acupuncture, Eye Movement Disassociation and Retraining and Emotional Freedom Technique have all got their acts together and published in reputable medical and clincal psychology journals. They have been or are in the process of being accepted by mainstream medicine because they have accepted the olive branch and the compromise. If they want to be compared to western medicine, they must follow shared rules on the quality of clinical investigations so that they can be directly compared.

And we should remember that even the best evidence based clinical psychology such as Cognitive Behavioural Therapy and Rational Emotive Therapy is hardly science. There are scientific explanations for the Behavioural Therapy side but the Cogntive side is based on the knowledge and understanding of the relationship between the human conscious and subconscious, both of which are a meaningless mystery in empricial scientific terms. 

Just because something sound highly sensible and rational, like the mind is capable of changing its thoughts and moods, does not make it science. Culturally, science appear to be trying to cement the illusion of its rationality by allowing these rational subjects to call themselves sciences for the kudos but there are not physical scientific mechanisms behind them. They are based on abstract philosophical mechanisms proven to be functioning working models by the real world clinical evidence.

Physiotherapy and the closely related chiropracters and osteopaths are more like human mechanical engineering than pure science. Their concepts are common sense and proven rather than being built on theories of how or why they work. The most important thing is that they do work. This is the fundamental underlying principle of Evidence Based Medicine.

Despite their lack of true scientific basis, these therapies have been fully accepted because of the high equality evidence that they have produced.

Other therapies have tried and failed. They have failed to produce objective results better than the placebo that they must be compared with. Some therapies that had been accepted by the western medical profession fell victim to more rigorous standards in clinical evidence. When Psychoanalysis was compared, it failed against The Great Healer Time and three hours per week of untrained human time and attention. What had to be proven was that the years of professional training of the analyst statistically improved outcome. For a therapy like Reiki to be proven as clinically effective, it would require that average Reiki therapists outperform average untrained people who attempt to relax patients using their hands to relaxing music.

The offer is open to them if thy dare to take it but they are not allowed to make up the rules.

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