Medical scientists and philosophers worldwide appeal to EBM to expand the notion of ‘evidence’, BMJ Evidence Based Medicine 2020

[MSEsperanza]

Anjum RL, Copeland S, Rocca E, Medical scientists and philosophers worldwide appeal to EBM to expand the notion of ‘evidence’, BMJ Evidence-Based Medicine 2020;25:6-8, https://ebm.bmj.com/content/25/1/6

Signatories include Greenhalgh and Wyller.

1. ‘Evidence’ is typically evidence of causation. Common terms used in EBM, such as ‘intervention’, ‘outcome’ or ‘increased risk’, are relevant to evidence-based decision-making only insofar as they point to causal matters: causal interventions and their effects.

Although there is growing reluctance to make causal claims in areas of uncertainty, the correct response to such uncertainty is not to avoid talking about causation but instead to improve our methods of understanding it.

[...]

5. Given the multiplicity of methods (cf 2) and a wide interpretation of what counts as a mechanism (cf 3 and 4), causation should be understood in non-reductionist terms. That is, the scope of relevant causal interactions extends beyond the molecular, pharmacological and physiological levels of interaction. Any thorough causal account should also include higher-level factors, such as the behaviour of tissues, whole organs and individuals, including psychological and social factors.

6. ‘Causal evidence’ should be extended to include different types of evidence, including case studies and case reports, which can in some cases provide valuable information for understanding causation and causal mechanisms. This is particularly important when dealing with rare disorders, marginal groups or outliers.

7. Patient narratives and phenomenological approaches are useful tools for looking beyond evidence such as symptoms and outcomes, and to elucidate the core causes or sources for chronic and unexplained conditions.

8. Causation has a non-negligible temporal aspect. Whether of long or short duration, a causal interaction cannot be fully understood from a ‘snapshot’, but requires both backward-looking perspectives (towards the origin) and forward-looking perspectives (towards the outcome).

More joint publications by 'Cause Health':
https://causehealthblog.org/the-team/

 

[Sean]

If you can't meet the standards, lower them.

 

[MSEsperanza]

I think this is not only about lowering standards, it's literally giving up logical reasoning.

Too much PEM now to make my points and maybe too much brain fog to be sure, but it seems to me that philosophers should do better. Or isn't logic essential for philosophy anymore?

 

[Hutan]

Wow.

it's literally giving up logical reasoning.

Oh, I think you are wrong, it's quite logical. You are just focusing on the wrong outcomes, outcomes like 'better health'.

Causation has a non-negligible temporal aspect. Whether of long or short duration, a causal interaction cannot be fully understood from a ‘snapshot’, but requires both backward-looking perspectives (towards the origin) and forward-looking perspectives (towards the outcome).

Think of outcomes more like knighthoods, feelings of moral superiority and insurance company largesse, and it becomes quite logical.

 

[MSEsperanza]

Wow.

Oh, I think you are wrong, it's quite logical. You are just focusing on the wrong outcomes, outcomes like 'soundly based treatments'.

Think of outcomes more like knighthoods, feelings of moral superiority and insurance company largesse, and it becomes quite logical.

Ah! Thanks Hutan.

Suddenly, it all makes sense, in particular the "higher-level factors, such as the behaviour of tissues, whole organs and individuals, including psychological and social factors".

 

[Trish]

What a load of waffle. I have yet to see any value in philosophers involving themselves in medicine.

By 'evidence if causes' in the context of treatments, do they mean, 'did the treatment cause the recovery/improvement?' And are they suggesting that case studies can provide as good evidence as controlled trials?

I'm lost.

Edited grammar

 

[richie]

We need some latitude on evidence because it happens many times that a condition is real and biophysical but is dismissed or psychologised for lack of biophysical evidence, at a current time, differences in approaches in different countries, or poor medical practice. As imo point 6 is fair.

I am more worried about 5) and 7) which can be used to dismiss or devalue the "lower level" causes which a given medic may wish to dismiss due to personal preconceptions.

"5. .....causation should be understood in non reductionist terms. That is, the scope of relevant causal interactions extends beyond the molecular, pharmacological and physiological levels of interaction. Any thorough causal account should also include higher-level factors, such as the behaviour of tissues, whole organs and individuals, including psychological and social factors".

a) Who defines reductionism? CBT/GET can be seen as reductionist as can LP etc. Biophysical does not necessarily equate with reductionist. Psychobehavioural and "higher level" may.
b) Who defines "relevant" and by what means? What is "relevant" cannot be pre-determined by a prior assumption of aetiology. How do they know that "the scope of relevant causal interactions extends beyond the molecular, pharmacological and physiological levels" in a given patient?It's medicine backwards. Why should "Any" i.e. "every", "thorough causal account include higher level factors.incl psychological and social factors". These factors may be "included" for consideration but then be dismissed as irrelevant to cuase or of low relevance. So, who defines "included" and how? It's the medicine backwards of reductionist BPS.

Because of this danger para 5 might be retained but rewritten for BPS enthusiasts:

"Given the multiplicity of methods (cf 2) and a wide interpretation of what counts as a mechanism (cf 3 and 4), causation should be understood in non-reductionist terms.That is, the scope of relevant causal interactions extends beyond the psychological and social factors and behaviour of individuals Any thorough causal account should also consider many levels of interaction. such as the behaviour of tissues, whole organs and individuals, including molecular, pharmacological and physiological levels of interaction. Current lack of knowledge and understanding re. biophysical bases of acondition cannot be used to assert psychological aetiology."

That should put the cart backk behind the horse whilst, in non reductionist way recognising the existence of both.

The fair minded might accept

"Given the multiplicity of methods (cf 2) and a wide interpretation of what counts as a mechanism (cf 3 and 4), causation should be understood in non-reductionist terms and careful consideration must be given as to what "non reductionist " means.The scope of relevant causal interactions may include molecular, pharmacological and physiological levels of interaction, the behaviour of tissues, whole organs and individuals and also psychological and social factors and behaviour of individuals. Psychological aspects of physical illness should not be dismissed but current lack of knowledge and understanding re. biophysical bases of a condition cannot be used to assert psychological aetiology. "

That should deal with the cases where lack of medical evidence is occasioned by failure to look for it by muppetry or by BPS prejudice or both.

 

[Jonathan Edwards]

What these people do not appear to understand is that evidence of all sorts is regularly used in working out causation in disease and treatment. I did it all the time. But each sort of evidence has a different level of reliability and there is NO argument for reducing standards of reliability at the point where you apply to clinical care.

They have simply missed the point with a straw man argument. But in doing so they have revealed their desire to rationalise so that they can believe what they believe works without getting reliable evidence. By putting a name to this someone like Greenhalgh simply emphasises their inability to understand what academic work is about.

Babble (Not otherwise specified).

 

[richie]

As a patient I have been happy for certain biophysical doctors to take action on the basis of evidence which other doctors would have dismissed as "no evidence". The quality of clinical care imo may be better where a doctor is willing to take a punt on a treatment where evidence of cause is questionable.

I agree fully that these (BPS) writers wish to "rationalise so that they can believe what they believe works without getting reliable evidence" though my demand for quality of evidence may be less than yours. I have had to be pragmatic as a patient.

What we might both agree on is that BPS thinkers seek to present unreliable evidence as reliable , since this is a part of their technique for getting MUPS patients onside. Biophysicalist "gamblers" do not need to do this, as a prescribed medicine does not have to be believed in for it to work. The doc just has to be confident that it will do no harm. I am glad I came across such biophysical gamblers, low grade evidence and all, and I see them as quite different from the BPS propagandists.

 

[Jonathan Edwards]

What we might both agree on is that BPS thinkers seek to present unreliable evidence as reliable , since this is a part of their technique for getting MUPS patients onside. Biophysicalist "gamblers" do not need to do this, as a prescribed medicine does not have to be believed in for it to work.

I don't think there is that much difference to be honest. Biophysical doctors have their patter for persuading patients too. Across the board a gambling approach to medicine has almost certainly done more harm than good. I think painting the BPS people as bad in a way that the biophysical gamers are not streaming on pretty thin ice. At least the BPS people have tried to do trials, even if badly. Surgeons are operating on PWME without ding any trials and probably leading to a number of deaths.

 

[chrisb]

This article is intersting in view of recent discussions. Perhaps we now have evidence of the efficaciousness of exercise for long-covid. But what sort of exercise? Apparently running on your own does not work (CG). Military style training may or may not, we cannot be sure. (PG). However a personal trainer will ensure success (CG).

All we now need to do is find out whether it is personal trainers in general, the methods of a particular trainer, or that particular trainer in person, that caused the effect.

It is suspected that these authors may have things "Aas about face".

 

[richie]

I don't think there is that much difference to be honest. Biophysical doctors have their patter for persuading patients too. Across the board a gambling approach to medicine has almost certainly done more harm than good. I think painting the BPS people as bad in a way that the biophysical gamers are not streaming on pretty thin ice. At least the BPS people have tried to do trials, even if badly. Surgeons are operating on PWME without ding any trials and probably leading to a number of deaths.

All I can say is I believe I am better for taking low risk chances and I know others too. In at least one case the weight of reasonable evidence has moved in the direction of the helpful Dr being on the right track. My term "gamblers" is not the best.
I am not convinced BPS conduct honest trials but regardless of personal integrity among practitioners, I still think a cardinal issue is their interest in patient compliance and belief. Their system does not incline them to objectivity since they want believing patients/clients.

 

[Peter T]

There are some grounds for offering people treatment based on what is seen as current best practice, even when it does not have a fully established evidence base. Indeed much of what clinicians do in practice is based not on solid research but what they saw their clinical supervisors doing. However you need to be up front with the patients that this is what you are doing.

Also there are also some circumstances where it may be appropriate to trial untested novel approaches, but again you need to be up front that this is what you are doing, ensuring the patient is in a position to make a fully informed choice.

The big problems come when the clinicians do not understand their evidence base. In the examples that we in the ME world are most familiar with is the BPS approach to ME and to so called functional disorders and MUS what many clinicians are arguing is both best practice and evidence based is neither, is actually contraindicated by the very evidence supposedly supporting it and wilfully excludes very real evidence of harm.

Though clinical practice at times may be in advance of the research base, it is never acceptable to lower standards of proof in order to justify that practice, rather such discrepancies should always be acknowledged and continuously reevaluated.

 

[Snowdrop]

I think it's about time for sensible people outside of our community who have the capacity to see through this to speak up forcefully against the demise of medical science. It's time for more people from more quarters to be engaged with this.

And to weigh up the consequences of this level of disdain for reality in favour of political propaganda.

 

[Jonathan Edwards]

Indeed much of what clinicians do in practice is based not on solid research but what they saw their clinical supervisors doing.

That was true in 1980 in my speciality but not since, at least in the UK and probably Europe I think. Everything has to be based on substantive evidence. Choices remain open if you have several equally grounded options to pursue and the way forward is always based on what the patient feels is in their best interest rather than what the clinician decides. But doing what your supervisors did has been scrubbed out of the training programme by emphasis on evidence-based practice. Interpretation of the evidence is not always perfect in guidelines but trainees are supposed to know about the range of points of view and the justification for each.

I think general practice is different in that GPs mostly have no idea what the evidence base for guidelines is, so are easily misled into accepting poorly founded guidelines.

 

[Snow Leopard]

If you can't meet the standards, lower them.

Patient narratives are important, but only when it's exactly what medical doctors want to hear!

 

[Peter T]

That was true in 1980 in my speciality but not since, at least in the UK and probably Europe I think. Everything has to be based on substantive evidence. Choices remain open if you have several equally grounded options to pursue and the way forward is always based on what the patient feels is in their best interest rather than what the clinician decides. But doing what your supervisors did has been scrubbed out of the training programme by emphasis on evidence-based practice. Interpretation of the evidence is not always perfect in guidelines but trainees are supposed to know about the range of points of view and the justification for each.

I think general practice is different in that GPs mostly have no idea what the evidence base for guidelines is, so are easily misled into accepting poorly founded guidelines.

I was not just thinking of doctors and of consultants, but of the health service as a whole, including the various other professionals. I qualified over forty years ago as a speech and language therapist and much of my first twenty years was spent working out what of what we did was evidence based and what was not, both within my own clinical specialism and within the services as a whole that I supported. I had to take early retirement over twenty years ago, so it is hard now to comment on the UK health service as a whole, but from my experience as a patient in relation to general practice and to the specialist ME/CFS services, I suspect current practice [added - in general] has not developed as much as you have experienced in a relatively well resourced and reasonably well defined medical specialism.

 

[Mithriel]

This whole area is typical of the way modern life has become full of agendas rather than straightforward truth. If a doctor finds that his patients are doing better on drug B rather than drug A, especially if it is cheaper and with fewer side effects that they report, then it does not need a full scale clinical trial before he can carry on with that choice.

Yet the reasonableness of the argument is being used to push forward on something that is not being mentioned.

For instance the "How to Overcome MS" leaflet says that evidence based medicine should mean all sorts of evidence including the experience of doctors and personal anecdote. But they are using this argument to push a program which includes selling their videos, leaflets, self help books and cook books possibly "training" sessions and lectures. The implicit idea that there is a way to not have MS anymore so if you carry on getting worse it must be your own fault is only recognised by the likes of us who have suffered from such reasoning.

The BPSers have honed this to perfection which is why we keep getting castigated and they can act all innocent.

 

[Kalliope]

Publication history

• Accepted September 21, 2018
• First published November 14, 2018.

Online issue publication
January 23, 2020

Does anyone know if it has received any reactions?

 

[rvallee]

This is obviously a non-starter, I hope reason prevails in not only dismissing this but responding in kind by raising the standards, rather than lowering them from their current state of: basically non-existent. Very likely in response to the NICE downgrading of evidence and other hits their mediocre body of evidence has received. That's the flaw in the system: even if they manage to push through mediocre research, it can be re-evaluated at any time and downgraded as too flawed to rely on.

It seems to be asking one especially absurd question: if something works, would we even be able to tell? Asking that question answers it. Relevance isn't supposed to be statistical and nothing else. If something works any competent evaluation should conclude correctly. Except EBM has been relying exclusively on irrelevant evaluations in the form of arbitrary psychometric questionnaires. They are less than reliable, since they don't ask about symptoms in circumstances where only symptoms are relevant, their preferred tools are inadequate to the task. But what they want is not for their ideology to work, but simply to be able to show that it does, as they believe, using the invalid instruments they have always used. Because they are easy and manipulable.

This is genuinely silly:

7. Patient narratives and phenomenological approaches are useful tools for looking beyond evidence such as symptoms and outcomes, and to elucidate the core causes or sources for chronic and unexplained conditions.

Symptoms and outcomes are the only relevant factors here, the way temperature is the only relevant factor for a room heater. Nothing else matters. And here they argue the only things that matter should not matter. Even though EBM in chronic illness has never bothered with those anyway. They simply want their psychometric questionnaires to be accepted because the entire body of evidence has been built on this.

I really hope long haulers clue in how just how toxic and harmful Greenhalgh is and have her and anyone promoting the BPS ideology excluded from anything related to LC. Ideologues should have no say in important matters, their goals have nothing to do with the mission of medicine.

Seriously EBM should be cancelled entirely. It is not a reliable method, it cannot validate anything by itself. We literally invented the scientific method because this ad hoc approach is too manipulable, which is necessary for charlatans and ideologues to promote their belief systems.