Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

JAMA Opinion Article in Support of Anecdote-Based Medicine

 
There is a horrible defense of ABM (Anecdote-Based Medicine) in the current issue of JAMA (Journal of the American Medical Association).

Apparently, because there is no evidence to support some things the author believes in, the problem is with the evidence.

For example –
 

There is no evidence to suggest that hospitalizing compared with not hospitalizing patients with acute shortness of breath reduces mortality.[1]

 

While R. Scott Braithwaite, MD, MS does appear to realize that it is therefore reasonable to conclude that we do not know if this improves outcomes, he advocates that ignorance intuition is bliss.

We had thousands of years of blood-letting that was based on Dr. Braithwaite’s flawed reasoning.[2]

We had thousands of patients killed by assuming, based on Dr. Braithwaite’s flawed reasoning that getting rid of ectopic heart beats would improve survival of patients who had already had a heart attack.[3]

Almost every proposed medical treatment does not make it through the FDA’s (Food and Drug Administration) evaluation of safety and efficacy.

Why?

When we require evidence, we find that most treatments fall into three categories.

1. Not effective.

2. Not safe.

3. Not safe and not effective.

What evidence satisfies Dr. Braithwaite’s flawed reasoning?
 

In each case, these hypotheses have been untested and therefore there is no evidence to suggest otherwise, presuming a definition of “evidence” that requires formal hypothesis testing in an adequately powered study.1 [1]

 

What is reference #1?

The satirical piece about parachutes that was published a decade ago.[4]

Does EBM (Evidence-Based Medicine) really work the way presented in a satire piece?
 

Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.[5]

 

Is it intellectually honest to base criticism of anyone, or anything, on an exaggeration?

If we accept Dr. Braithwaite’s flawed reasoning, yes.

But Dr. Braithwaite’s flawed reasoning is dangerous.
 

However, deciding to intervene when “there is no evidence to suggest” also may make sense, particularly if the intervention does not involve harm or large resource commitments, and especially if benefit is suggested by subjective experience (eg, the qualitative analogue of the Bayesian prior probability).6 [1]

 

Dr. Braithwaite’s wishful thinking is encouraging him to experiment on people with no ethical approval and no acceptable documentation for research purposes.

You are Dr. Braithwaite’s guinea pig and he says that it is unethical to withhold a treatment that is based on logical fallacies, such as cherry picking[6] and basing decisions on sample sizes too small to produce any valid information.[7]
 

I want to know the real risks and benefits of this treatment.


 
 

Beyond its ambiguity, “there is no evidence to suggest” creates an artificial frame for the subsequent decision. It may signal to patients, physicians, and other stakeholders that they need to ignore intuition in favor of expertise, and to suppress their cumulative body of conscious experience and unconscious heuristics in favor of objective certainty.[1]

 

Ignore intuition, rather than choose a treatment based on intuition?

Dr. Braithwaite does not go that far, but he does claim that a lack of evidence of harm justifies abuse treatment by intuition.

Footnotes:

[1] A piece of my mind. EBM’s six dangerous words.
Braithwaite RS.
JAMA. 2013 Nov 27;310(20):2149-50. doi: 10.1001/jama.2013.281996. No abstract available.
PMID: 24281458 [PubMed – in process]

[2] Answer to What is this Dangerous Treatment and How Long Did it Take to Stop Using it
Wed, 01 Feb 2012
Rogue Medic
Article

[3] C A S T and Narrative Fallacy
Mon, 20 Jul 2009
Rogue Medic
Article

[4] Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
Smith GC, Pell JP.
BMJ. 2003 Dec 20;327(7429):1459-61. Review.
PMID: 14684649 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[5] Evidence based medicine: what it is and what it isn’t.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS.
BMJ. 1996 Jan 13;312(7023):71-2.
PMID: 8555924 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[6] Cherry picking (fallacy)
Wikipedia
Article
 

Cherry picking, suppressing evidence, or the fallacy of incomplete evidence is the act of pointing to individual cases or data that seem to confirm a particular position, while ignoring a significant portion of related cases or data that may contradict that position. It is a kind of fallacy of selective attention, the most common example of which is the confirmation bias. [1] Cherry picking may be committed intentionally or unintentionally.

 

[7] Hasty generalization
From Wikipedia
Article
 

A person travels through a town for the first time. He sees 10 people, all of them children. The person then concludes that there are no adult residents in the town.

 

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Comments

  1. How is this man not supreme medical commander of all of the EMS agencies in ‘Merica! ?

  2. I like how he considers the proposal that, “There is no evidence to suggest that ambulances compared with taxis to transport people with acute GI bleeds reduces prehospital deaths,” to be completely absurd, when I actually think it’s a pretty reasonable statement. First, there’s really not much to be done in the prehospital setting for GI bleeds besides airway management, so it’s not like ambulance crews possess some magical GI bleed fixing medications that cab drivers don’t.

    Second, I can guarantee a cabbie would spend less time on scene with a GI bleed than any EMS crew, thus reducing the amount of time in the prehospital setting. While this shortening of time from prehospital contact to ED arrival might not necessarily decrease overall mortality, there’s a good chance it actually would decrease “prehospital deaths” simply because there’s less time in the prehospital setting for that outcome to occur.

    Tis a shame his attempt at reductio ad absurdum failed by not being absurd enough, and it’s doubly shameful that his failure to do so highlights how few prehospital interventions have an evidential basis and how poor we are at really addressing what it is that EMS is good at and what we can do without.

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