Evidence-based

The central notion of evidence-based medicine is that our understanding of human biology is imperfect.  Some of the idea we come up with for  treating and preventing disease are effective, but most are not, worse than useless. So we need careful, rigorous statistical studies before implementing those ideas on a wide scale. A good example of doing this the wrong way was when when doctors started recommending having babies sleep prone,  which roughly doubled the incidence of sudden infant death syndrome for the next several decades.

It seems to me that our understanding of psychology, sociology, economics, political science, and education is at least as imperfect as our understanding of biomedicine.

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56 Responses to Evidence-based

  1. The fourth doorman of the apocalypse says:

    A good example of doing this the wrong way was when when doctors started recommending having babies sleep prone, which roughly doubled the incidence of sudden infant death syndrome for the next several decades.

    Perhaps doctors were simply engaging in an experiment that did not run past any ethics committees (because they might not have gotten approval.)

  2. Hesse Kassel says:

    It’s very easy to pick out mistakes and imperfections after the fact then claim to be smarter and able to do better, at least by implication. It seems to be a very common theme on this blog.

    Back in the real world it’s a lot less easy to avoid them under conditions of limited information, incomplete knowledge and collective decision making.

    The implied solution here always seems to be a kind of top down control of the world by a self proclaimed elite. That always seems a good idea, but history indicates that it doesn’t always work out so well.

    • gcochran9 says:

      “Measure twice, cut once” – can’t get much more elitist than that!

      Carefully testing innovations on a small scale before widely implementing them is pretty much the opposite of what self-appointed elites have done. Are you deef or something?

      • Hesse Kassel says:

        I don’t recall saying anything about not testing innovations before using them on a large scale. It’s unlikely we would find anyone who would disagree with that one, at least in principle.

        Far from being deaf, you apparently have such amazing senses that you hear things which no one said at all.

    • Zippy says:

      Hesse, you have it exactly backwards.

      It’s the current self-proclaimed credentialed elites who want top-down control. Instead of saying honestly “we have limited information and incomplete knowledge,” they foist policies upon us based on overstated certainties.

      So doctors confidently say “have your babies sleep prone,” when in fact the evidence for that position was never very good. Or they say “avoid saturated fat, eat those healthy vegetable oils instead.” They still aren’t admitting that one was wrong, despite the fact that Ancel Keys has been pretty definitively proven to be a scientific fraud.

      And then the “experts” confidently deny things that are obviously true, human biodiversity being the most obvious elephant in the room.

  3. IC says:

    I learned this through one of our end-stage cancer patients who surprised me when she came back back to clinics after a year without following up and treatment. We thought she might have died in other health care facilities. Normally patients with her stage will die within a year. When she left without following up and treatment, she used only baking soda for treatment without any other medicine. Finally after a year, she was still alive and felt ok, then she decided to have a check up. On imaging studies, her tumor shrank.

    We are all puzzled. We really do not know whether should take this alternative medicine seriously or not. We still do not recommend this to other patients. The entire thing still can be coincidence.

    https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=baking%20soda%20cancer

    Evidence or coincidence is the question.

  4. Justin says:

    Word up. Physics can’t predict earth quakes, economists can’t foretell recessions better than markets. Listen to Robb Wolf before your physician.

    • IC says:

      If you have trauma due to accident or gun-shot, better listen your physicians first before any thing else. Despite of imperfection of modern medicine, evidence is still pretty strong that doctors can save your life in quite a few of situations.

      Do not throw the baby out with bath water.

  5. Sean II says:

    One serious obstacle for evidence-based medicine is that people are afraid to control for certain variables, well known to readers of this page. The P5T crowd – piss poor protoplasm, poorly put together – consumes a lot of health care, but they don’t consume it very well. Their lack of compliance with treatment mucks everything up, as does their amazingly consistent “bad luck” (see also: Appalachian Emergency Room).

    Probably they should be thrown out of evidence, or better yet studied separately, but they’re not. Their lousy outcomes cloud the picture for everybody else. Just one more way that the denial of human nature makes nature less hospitable to humans.

    • Jim says:

      An astonishing percent of prescriptions are not filled even once.

      • Sean II says:

        Yep, and it’s the heartbreak of many PGY-1s to bust their ass putting somebody on a treatment plan with options meticulously chosen from the $4 list, only to find that what the patient meant by “I can’t afford my pills” was really just “I can’t be bothered, not at any price”.

        This has implications outside of medicine. To use a very obvious example, let’s say someone tried to take the evidence-based approach to law enforcement. What would they find?

        Well, if you control for demographics it’ll turn out American policing has been a stunning success, protecting some of the safest people who’ve ever walked on planet Earth at a pretty reasonable price vis-a-vis the per capita GDP of those protected.

        If you don’t control for demographics, it’ll turn out American policing is an expensive catastrophe, frequently suspected by its own clients of conspiracy and murder.

        • Andrew Ryan says:

          Very good analogy. One can make a similar point regarding K-12 education. If you control for race the American system works very well, roughly equivalent to other developed countries for “white” students (includes many hispanics, hence the quotes) and superior to African for black students and Latin American countries for hispanics. If you don’t control for race and just average everyone together it’s a disaster, and you get situations like Paul Krugman claiming that higher teacher union membership is why students in Minnesota perform better than in Texas, when students of every demographic group perform equivalently or better in Texas once you control for race.

        • amac78 says:

          If you don’t control for demographics, it’ll turn out American policing is an expensive catastrophe, frequently suspected by its own clients of conspiracy and murder.

          You were doubtlessly thinking of Jill Leovy’s Op-Ed in this weekend’s Wall St. Journal, The Underpolicing of Black America. In order to ignore the HBD elephant, Ms. Leovy has to put the passive tense through an impressive workout. Black people get murdered in black neighborhoods, but the mysterious details hide behind an impenetrable fog. Therefore, Underpolicing is at fault.

          • Sean II says:

            I hadn’t seen that specimen, but man does it put the conform in conform to expectations.

            You gotta admire the centre-right’s ingenuity. They have to avoid both the truth AND the tropes of leftism, to forge their own brand of frivolity. It’s a delicate dance.

  6. “The central notion of evidence-based medicine is that our understanding of human biology is imperfect. Some of the idea we come up with for treating and preventing disease are effective, but most are not, worse than useless. So we need careful, rigorous statistical studies before implementing those ideas on a wide scale.”

    But that is NOT the central notion of evidence based medicine – any more than the central notion of communism is that everybody should be happy and prosperous.

    The evidence based medicine movement is merely a superficially-plausible, and by now almost wholly successful, excuse for ‘managing’ medicine by external groups such as the government and Big Pharma.

    http://charltonteaching.blogspot.co.uk/2009/08/zombie-science-of-evidence-based.html

    And Pharmageddon- by David Healy

      • DrBill says:

        It would be easy enough to figure out who is right. Just run an RCT or three, randomizing people into evidence based medicine and into evil individual medical judgment.

        Odd that the ebm true-believers true believe in the absence of such evidence. Especially odd given the stated ideology, goals, and methods of ebm. It’s almost as if they grant their own goofy theories a special no-need-to-verify epistemic status.

        But, but, they’re not theories! They’re, they’re, the way things are!! Because . . . SCIENCE!!!!1! Here, I’ll send out an RFP for philosophers of science to write papers arguing that ebm is SCIENCE!!!1! Believe me now? No? OK, here’s an RFP for medical ethicists (stop laughing, fucker!) to write papers arguing that saying ebm isn’t science is unethical. Now shut up!

        Alternative answer: utter the prefix “meta” and smirk.

  7. Tim Howells says:

    Great post! I’ve been working in medical research for many years now – starting just about the time that the “evidence-based” concept really got traction. I’ve found it to be a really worthwhile discipline. I often find myself wishing that politicians, educators, sociologists etc etc would accept these standards in their own fields.

  8. John says:

    What are your thoughts on using the paleo-diet rather than vaccination? Could it be an effective substitute?

    http://www.azcentral.com/story/news/12-news/2015/01/23/12news-doctor-dont-vaccinate/22200535/

    Despite a recent measles outbreak in California, a Valley doctor believes children should not get vaccinated and that they should be getting this kind of infection.

    “We should be getting measles, mumps, rubella, chicken pox, these are the rights of our children to get it,” said Dr. Jack Wolfson of Wolfson Integrative Cardiology in Paradise Valley.

    Wolfson does not believe in vaccination. “We do not need to inject chemicals into ourselves and into our children in order to boost our immune system,” he said.

    The cardiologist also believes the key is to have a healthy immune system. In order to have that, he says, you have to avoid chemicals, get enough sleep, exercise, take good supplements, and have proper nutrition.

    “I’m a big fan of what’s called paleo-nutrition, so our children eat foods that our ancestors have been eating for millions of years,” he said. “That’s the best way to protect.”

    • gcochran9 says:

      Wolfson should be burned at the stake. Then the ashes should be mixed into clay, made into sturdy, heavy pots, when would then be periodically ritually smashed over the heads of prominent anti-vaxx people.

    • ursiform says:

      Does he believe kids should get smallpox and polio, as well? What an idiot!

    • Andrew Ryan says:

      Notice he’s a cardiologist and not an Infectious Disease doc (nor a Nutritionist, for that matter). I think the Paleo diet can be beneficial for weight loss (as can any low carb diet) but as a substitute for vaccination it is absolutely insane. Edward Jenner was vaccinating against smallpox nearly 300 years ago. Have we really regressed this far?

  9. Sandgroper says:

    Massively off-topic, to try to offset the ugly idiocy of Wolfson, here’s a picture of the world’s best female middle distance runner. She’s come some way from the goat farm, from the look of her apparel. Looks like a fine Neolothic girl to me:

    http://www.iaaf.org/news/news/genzebe-dibaba-iaaf-athletics

    • ursiform says:

      In other words, you have the hots for her?

      • Sandgroper says:

        In truth, I have. I think she’s a doll, and fully deserving of being the Bear Cult mascot.

        But any girl who can break 3 world records over 3 different distances in 3 different countries in the space of 3 weeks deserves some respect – the only athlete male or female to have ever done it. I love watching her run.

        She would have done more over the 2014 summer outdoor running season too, but had a persistent back injury, so had to confine it to just the one 5,000m win and no additional records. So, I guess we’ll see what she can do in 2015. Remember the name for the 2016 Olympics – Genzebe Dibaba.

        • kai says:

          yes, she is a little bit narrow in the hips (it helps for running 😉 ), but i would not think twice 😉

          I think the dibaba family really have bet on mid-long distance running, they obviously have it in high regards and raise their childrens with this goal in mind, training crazy hours. Probably have developped secret running technique too, that’s the only explanation why the whole family is so succesfull, they hit just the right mix of hard work and motivation. I heard that ethiopian culture gives a lot of prestige to runners too, it probably help.

          Genetics has nothing to do with it 😉

          • Sandgroper says:

            I appreciate you are joking, but just to confirm, a while back, Greg and I dug out some race results (running races, not…) and family histories- the reason almost all middle and long distance races are now dominated by Ethiopian and Kenyan Highlanders, often whole families of them, is genetically conferred high altitutude adaptation that gives their blood higher oxygen carrying capacity…plus a lot of hard training, of course, but offset by poor training facilities.

            The case for that is now absolutely compelling.

          • kai says:

            Yes, I was joking of course. Her sister Tirunesh looks (not surprisingly) a lot like her, although not as attractive imho (still, far from bad). I suspect that in addition to ethiopian highlands adaptation (they come from the right place), girls from this family have narrow hips (man-like). So, double advantage, expect more champions from this family. I wonder if they have have a lot of C-section in the family too…I would expect yes, and a high rate of C-section in female athletes in general…

            Everybody doing athletics train hard, so results are almost purely from genetics imho, especially at high level and for “non-technical” disciplines.

            What was hilarious in your link was this sentence:
            “With a fifth Dibaba sister, 16-year-old Melat, still to come, and their brother, 24-year-old Dereje, a marathon runner, there must be quite some secret to the family gift?”
            Yes Sherlock, I wonder also what’s the secret…I love journalists lol….

          • Sandgroper says:

            Yeah – you can hit journalists over the head with the obvious, but…it also carries with it the reality that genes trump everything, which a lot of journos either find distasteful, a touchy subject or just don’t understand enough about genetics to grasp. Certainly, the term “high altitude adaptation” was used in relation to male Kenyan distance runners when I was a kid, so it’s not like it’s a thought that has just hit everyone.

            There’s a political dimension (isn’t there always?) – Ethiopian athletes are migrating to other countries so that they can compete at international level, when they would not be good enough to make the cut in Ethiopia. So we have the potentially slightly ridiculous spectacle of an international race, all of the competitors in which are ethnic Oromo but representing their countries of adoption. Personally, I don’t care. If they are the world’s best runners over those distances, then they are. I don’t see people objecting to American and West Indian sprinters of West African ancestry dominating all the sprint events – at least, not seriously objecting, although you get the inevitable mumbling. But anyway, I can see why the athletes themselves might want to diplomatically steer conversation away from what must be genetically obvious to them

            I don’t know about the C-section thing. Older sister Tirunesh is currently pregnant, and she is as bird-hipped as Genzebe (although as you note not quite as cute – her nick-name is the Baby Faced Killer). The pelvis dislocates somewhat during delivery, so I guess as long as the birth canal is large enough it’s not a problem. It didn’t prevent their mother having multiple kids. Tirunesh is done with middle-long distance now – after she spends long enough producing kids, she is going to train for marathons. It looks like Genezebe is now going to concentrate on 5,000 metres, although previously she has had notable success with 1,500 and 3,000. It seems they do well early at the shorter distances, then as they gain stamina but perhaps lose a yard of pace with age they move up and do better at the 5,000 and 10,000, and then round out their careers with marathons. It looks like Genzebe will target the 3,000, 5,000 and maybe 10,000 in the 2016 Olympics, and then see where she goes from there. As long as she has no chronic back or other injury issues, she has already demonstrated that she is capable of tackling multiple distances over the space of a couple of weeks.

            • gcochran9 says:

              You don’t want to start out by hitting journalists over the head with the obvious: first, you hit them over the head with a two by four, just to get their attention.

      • Asher says:

        I cannot say she’s unattractive.

  10. Sandgroper says:

    In a very seriously messed up bit of communal chattering, you can see to what Wikipedia attributes the athletic prowess of the Kalenjin of Kenya: http://en.wikipedia.org/wiki/Kalenjin_people

    It’s the male and female circumcision rites. Well, it’s obvious, it has to be that. And the skinny legs. Altitude adaptation? Nah!

    Greg, hand me that two by four, would you?

    • kai says:

      That was funny, indeed the foreskin is such a dead weight lol

      Still, to Wikipedia credit, both high altitude adaptation and body type/leg morphology are cited, and those are the most obvious adavantages you can think of.
      Probably too obvious, immediately visible and heritable, I guess that’s why they have to be obfuscated…

  11. Tom Bri says:

    As for putting babies prone, good solid reasons to do so, as those old docs knew well. Just this week I did a training rotation in a neonate ICU. The babies were often put on their stomachs. Better breathing, and better digestion. I watched the blood o2 monitor reliably sink down when the babies were on their backs, and rise when turned over. No explanation for why this is, but the babies certainly seemed to prefer it. Too bad about the SIDS.

    • gcochran9 says:

      Those aren’t the reasons people used in arguing for sleeping prone: they talked about supine sleepers spitting up and choking, which in practice doesn’t seem to happen. As for what you suggest, I don’t believe it.

      • Tom Bri says:

        Not sure just what I suggested that you don’t believe. If it is that preme babies respond better on their stomachs than on their backs, well, I saw it on the o2 monitor with my own eyes. See:
        http://sids-network.org/experts/pronepos.htm
        for some pros and cons. I don’t claim any particular expertise in that field, but the nurses there certainly believed it. By the way, these babies were all very low birth weight, with respiratory problems. They had o2 supplementation via nasal canula, so low risk for suffocation while prone.

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  13. The fact that people practiced certain methods for thousands of years is a good indication of their efficiency. It is time-tested. It does not need laboratory because life is a laboratory.

    And if a practice appears independently in many cultures, it is a very good sign.

    • Tom Bri says:

      I have often wondered if smoking had some positive effect in prior eras. Possibly keeping mosquitoes away? Also, heavy drinking in killing bugs in the gut, or in repelling insects from the skin?

      • gcochran9 says:

        As a major health hazard, smoking starting showing up in the 1920s, with cigarette-rolling machines.

      • I believe all the mind altering substances of the past are/were useful. Some for mental benefits, some for physical health. Moderate alcohol drinkers live longer, however correlation does not imply causation. These substances strengthen within group ties. Recent drugs (pure extractions) are probably dangerous as they are not time-tested.

        And most art is the result of these substances or suffering.

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