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"Eminence Based" Medicine versus Evidence Based

E v eThanks to Laura Hayes for the heads up on this fascinating article on a term I  had never heard; "Eminence-baed" medicine.  Kim

Published in MedPageToday, by Larry Husten

The Big Dirty Secret Every Doctor Knows

Lately I've been writing about eminence-based medicine (here, here, and here). In response to these posts, Saurabh Jha, MBBS, a well-known radiologist and health-policy critic, asked me on Twitter: "How do you find these utter gems?!"

I was surprised by Jha's question, because the evidence for this phenomenon -- eminence-based medicine trumping evidence-based medicine -- seems overwhelming.

But then I realized Jha's question was legitimate, because there's actually remarkably little hard proof, though I suspect it really is a big dirty secret that every doctor knows in his or her heart.

For this reason, I think Bernhard Meier, the interventional cardiologist I've been writing about, deserves praise for, at the very least, being so honest and forthright. In his article in European Heart Journal and in his response to my questions he was perfectly willing to explain and defend his position. One of the refreshing aspects of Meier's positions is that he readily admits that his actions fly in the face of evidence-based medicine. In his EHJ article, he specifically stated that randomized controlled trials are an artifact of the past. His beliefs and practices, he explained, were developed from his long experience at the pinnacle of interventional cardiology.

By contrast, most eminence-based medicine is dressed up in the guise of evidence-based medicine. The distinguished thought leader will provide a ceaseless barrage of statistics, of which he (or she, but usually he) will have an unparalleled mastery. At each step of the argument, the logic will appear flawless, even brilliant. But, in general, the entire purpose of the talk will be to "prove" the thought leader's opinion, despite the complete lack of genuine reliable evidence, or to disprove the actual evidence that exists, because it fails to support that opinion.

But the responsibility for eminence-based medicine goes well beyond the elite coterie of experts. The real problem is the culture of medicine, which rewards the hubris of eminence and actively punishes or offers subtle disincentives to anyone who question this process.

In this respect, medicine mirrors the rest of life. Medical training is disturbingly similar to military training, where immediate and unreflecting obedience is the goal. Both basic training and residency are designed to break down the mindset and instincts of a young person in order to mold them to the needs of the profession. In both, the submission to authority is a central tenet....   Read more at the MedPageToday site.

Comments

Benjamin

Wow - The Cornell link (EPA 2002) regarding pyriproxyfen now gets a 404 - it worked a few days ago. Surely just a temporary technical glitch...

ATSC

Benedetta,

Here it is:

http://web.archive.org/web/20100715091813/http://www.telegraph.co.uk/health/3339154/I-wanted-to-rip-the-autism-out-of-her.html">http://www.telegraph.co.uk/health/3339154/I-wanted-to-rip-the-autism-out-of-her.html">http://web.archive.org/web/20100715091813/http://www.telegraph.co.uk/health/3339154/I-wanted-to-rip-the-autism-out-of-her.html

Benjamin

Jeanette -

Had a brief online discussion with John Lapage, a postdoc at Warwick University currently working on the Zika virus. He provided a heap of 'evidence' supporting his claims as to a causative link between Zika and microcephaly while 'debunking' those who disagree. I had a brief look into some of the evidence - apparently the World Health Organisation has tested for possible side-effects one of twelve pesticides, namely pyriproxyfen. They claim that its effects on human health are negligible. Problem is pyriproxifen - along with the other eleven pesticides - are recommended by none other than WHO. The following link indicates that the toxic side-effects of pyriproxifen are still relatively unknown: http://pmep.cce.cornell.edu/.../pyriprox_tol_0802.html

I pointed out the almost unavoidable bias of WHO's coverage to Lapage. He assured me that no causative link has been demonstrated between the pesticide and Zika. I left it at that, for to be sure, he seemed a decent enough fellow, and really, why be bothered arguing with a scientist who's obviously content to overlook pretences so unsound?

Jeannette Bishop

@Benedetta,

There's this link:

http://www.telegraph.co.uk/news/health/3339154/I-wanted-to-rip-the-autism-out-of-her.html

Benedetta

Sam Cams the Telegraph says it can no longer find that there page. Sigh.

Sooo Did Dr. Wakefield or any one else find out who this family member of the Blair's was?

Jeannette Bishop

Zika virus is the current "eminent" problem, I think:

http://www.healthnutnews.com/zika-pesticide-linked-60-increase-autism-yet-sprayed-big-cities-everywhere/

So, they are spraying with a pesticide they will admit appears to increase autism risk...what is this? Pick your poison? Take a vaccine with unknown risk to the unborn, because it might be safer than spraying ostensibly to prevent a "eminently" pronounced risk to the unborn?

Benjamin

John

Tell you what - if the genetics revolution really takes off then all you would need is a board-certified doctor telling his patients that he/she has no genetic predisposition to be submissive to authority. Imagine the effect that might have! But you know, just speculating in the absurd...

kapoore

Thank you, Laura Hayes, for always speaking the truth despite a wall of propaganda and deceit. So here are my thoughts on science, scientism, etc.

Accepting authority without question was once called Scholasticism, which was the philosophy of Medieval Europe. Scholastics disputed topics based on the accepted authorities. Maybe it went something like this--Aristotle said this, St. Augustine said that, etc. Scholasticism was challenged in the early Renaissance with knowledge based on measurement. Now we have measured practically everything that is possible to measure, we have it seems returned to "Scholasticism," as in the CDC says this, the FDA says that, Paul Offit says this, Gregory Poland says that. Therefore this is all true. Right? No measurements necessary.

Good doctors have to be informed but they also have to be active thinkers and problem solvers. I know an experienced surgeon who in the midst of an appendectomy felt he was missing something. Yes, the appendicitis was causing a problem but there was a hidden problem as well. He discovered that the real problem was a tiny bristle of a barbecue brush that had lodged itself in the organ cavity. Once this was removed the patient experienced complete recovery.

We want doctors to be well educated in their fields. We want them to question authorities just as those who first set out on the great project of measuring the world had to first question authority. And we want active thinkers. Is that too much to ask of the highest paid professionals in our society?

John Stone

Rae:

SamCams step-sister http://www.telegraph.co.uk/health/3339154/I-wanted-to-rip-the-autism-out-of-her.html

Relative of Cherie Blair
http://www.dailymail.co.uk/news/article-91387/MMR-jab-Cherie-relative-autism-victim.html

John Major's grandson http://www.dailymail.co.uk/news/article-1055646/My-dad-does-neglect-autistic-grandson-Sir-John-Majors-son-defends-PM.html

Rae

John,

Which three Prime Minister families were they, and what was the connection? Thanks.

John Stone

Benjamin

That's really telling isn't it? It's the social status of the paper that is really being measured!!! Equally, if you want to stay in public life you have to abandon unfashionable opinions or you will be hounded. Three British Prime Ministers in the last two decades had families touched by autism but they jumped into line. In power but actually controlled by class affiliations, looking smart, and absolutely nothing to do with science.

Benjamin

It might have been Schopenhauer who said that about eight tenths of the population accept a proposition on the word of authority that it is true irrespective of whether it really be so or not, while the remaining two tenths may do so on the strength of the proposition alone. (Which begs the question - does this statement hold validity to you even if it isn't by Schopenhauer?)

I experienced a perfect instance of this. I showed an interesting and controversial scientific article to a highly regarded plastic surgeon, who read it through in a state of apprehension, then exclaimed 'but this publication, I've never heard of it, the quality of paper and print is not very good, I'd say that it can be disregarded".

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