Evidence-based medicine

[[File:Graunt - Natural and political observations, 1676 - 204.tif|thumb|right|165px|The beginning]]
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{{cquote|Without the aid of [[statistics]] nothing like real medicine is possible.|||[[Pierre Charles Alexandre Louis]]<ref name=evidence>[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296268 Evidence-based medicine: old French wine with a new Canadian label?''], P K Rangachari, J R Soc Med. 1997 May; 90(5): 280–284.</ref>}}
'''Evidence-based medicine''' ('''EBM''') is the application of the [[scientific method]] to [[medicine]]. This is done by applying modern scientific and statistical methods, to help make [[rational]] decisions for individual patients, based on the available [[evidence]] and our existing body of knowledge.

==Why EBM?==
In the thousands-year old history of medicine, medical decisions have been based on careful observation mixed with [[superstition]]. Many of the ancient physicians were excellent observers of human disease — but [[Protoscience|they lacked the tools]] to describe mechanism of disease, and therefore were impotent to intervene.

Many of the disease descriptions and prognostications made by such writers as Hippocrates still ring true today. Their treatments, unfortunately, do not.

Until very recent times, the ''experience'' of very talented individual doctors was still the basis for medical decision-making. EBM is an attempt to relieve the individual of this impossible responsibility, utilizing their talents, but adding objective knowledge to the mix.

Epidemiology and statistics were pioneered together by {{wpl|John Graunt}} in 1663 with his publication, ''Natural and Political Observations upon the Bills of Mortality''.<ref>''Natural and Political Observations upon the Bills of Mortality'' by John Graunt (1663).</ref> There was initial resistance to Graunt's work and epidemiology could not advance without the concomitant advance of statistics, which did not substantially happen until the late 19<sup>th</sup> and early 20<sup>th</sup> centuries.<ref>{{wpa|History of statistics||.}}</ref> The breakthrough in the use of modern epidemiology came with the 1954 publication of the {{wpl|British Doctors Study||,}} led by Richard Doll and Austin Bradford Hill, which ''evidentially'' showed the link between [[tobacco]] smoking and lung [[cancer]] using statistics.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC437141/ The mortality of doctors in relation to their smoking habits: a preliminary report] by Richard Doll and Austin Bradford Hill (1954) ii:1451-1455 ''British Medical Journal''. doi:10.1136/bmj.328.7455.1529.</ref> Subsequently, epidemiology is now the standard for determining disease causes (etiology) and effective disease treatment.

==How does it work?==
EBM focuses both on diagnosis and treatment. Diagnostic tests are usually tested vs. a [[gold standard (science)|gold standard]] using specific statistical techniques. For treatments, medical problems are identified, interventions are devised and systematically tested. If an intervention is validated by sufficient [[evidence]], it is usually adopted.

==Example, please?==
===Diagnosis===
Pulmonary embolism, or blood clots that go to the lung, are a major cause of death and disability. They are notoriously difficult to diagnose, with protean symptoms and signs. A clever team of researchers based at the University of Michigan decided to ask how to best diagnose the condition. They set up a statistically valid study in which one modality (in this case, something called a "V/Q Scan") was tested against a gold standard, in this case pulmonary angiography, where a catheter shoots dye directly into the blood vessels to look at the clot. Why not just do that every time? It takes more time, more skill, and is more dangerous. Based on their results, a decision-making algorithm was designed to help better diagnose pulmonary embolism. (This is now a bit outdated, but the example stands.)

What about the doctor? Doesn't she have to, you know, ''do'' anything? Yes. They must suspect the condition, know how to apply standards of evidence, know the literature, and not waste a lot of time equivocating. They must communicate with the patient, comfort them. EBM is ''not'' a substitute for human doctors.

===Treatment===
Scientific principles tell us that medications that prevent blood from clotting should help treat pulmonary embolism. This turns out to be true, but the best way to "thin" someone's blood cannot be known without applying science. Studies have been done on the type of anticoagulant, duration of treatment, etc. All of this has improved the care of patients with this condition.

What about our brave doctor? Are they left out of this part, too? Fortunately not. Evidence guides us as to what medications to use and for how long. But blood thinners are dangerous. What if the patient is elderly and tends to fall a lot? Is it safer to give blood thinners for a long time or not to give them? This requires knowledge mixed with art.

==The end?==
In December 2017, the [[Donald Trump|Trump]] administration tried to put the kibosh on evidence-based medicine by issuing a directive to the [[CDC]] [[Censorship|forbidding the words]]: vulnerable, [[Entitlement program|entitlement]], diversity, [[transgender]], [[fetus]], '''evidence-based''', and '''science-based'''.<ref name=sun>[https://www.washingtonpost.com/national/health-science/cdc-gets-list-of-forbidden-words-fetus-transgender-diversity/2017/12/15/f503837a-e1cf-11e7-89e8-edec16379010_story.html CDC gets list of forbidden words: Fetus, transgender, diversity] by Lena H. Sun and Juliet Eilperin (December 15, 2017 at 6:53 PM) ''The Washington Post''.</ref> It was suggested by an unnamed Trump official that the [[Euphemism|euphemistic]] statement "CDC bases its recommendations on science in consideration with community standards and wishes" be used instead of "science-based" or ­"evidence-based."<ref name=sun/> Such a change would significantly water down the meaning of evidence and science because it would allow for (at least implicitly) the introduction of [[pseudoscience]] from the "community".

The directive was quickly and also anonymously rescinded, but it may have a similar stifling effect by inducing career staff to self-censor.<ref>[https://www.npr.org/2017/12/16/571329234/trump-administration-reportedly-instructs-cdc-on-its-own-version-of-7-dirty-word Trump Administration Reportedly Instructs CDC On Its Own Version Of 7 Dirty Words] by Brakkton Booker (December 16, 201712:14 PM ET) ''NPR''.</ref>

===The end, for real?===
{{see| Centers for Disease Control#Censorship}}
At the start of the second Trump presidency, he tried to do this again, this time, thanks to the seeming huge amount of power he now posses, even doing worse and somewhat succeeding. Same method as he tried before, censoring certains words because god forbid ''facts don’t align with your feelings'', so might as well censor them.<ref>[https://www.theverge.com/news/604484/donald-trumps-data-purge-has-begun Donald Trump’s data purge has begun], The Verge, February 2nd 2025 (retrieved April 1st 2025, I wish it was a joke)</ref>

==Summary==
EBM has revolutionized medical science. It has helped minimize decisions based on superstition and "common sense," though it is not without its flaws. Some of its techniques are nearly impossible for the individual physician to apply, and it often relies on the statistics of populations and samples that may or may not apply to an individual patient given the manifold variations of human biochemical makeup. Flawed as it can be at times, it is none-the-less the best science and rational thought currently has to offer. It stands at the gates of medicine and guards against [[quackery]].

It's worth stressing here that, while evidence-based medicine freely admits to being flawed, it is substantially ''less flawed'' than the [[alternative medicine|alternatives]], which aren't so willing to admit to having flaws of their own.

==See also==
*[[Alternative medicine]]
*[[The dose makes the poison]]
*[[Hierarchy of evidence]]
*[[Medicine]]
*[[Science-Based Medicine#Premise|Science-Based Medicine § premise]] — proposed as an improvement upon EBM
*[[Scientific method]]

==References==
{{reflist|2|80%}}

[[Category:Medicine]]
[[Category:Arguments against evidence-based medicine]]

Categories: Medicine, Arguments against evidence-based medicine