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Letters to the Editor  |   April 2008
Embrace Evidence...With Both Eyes Open
Author Affiliations
  • John M. McPartland, DO
    Middlebury, Vt
Article Information
Evidence-Based Medicine
Letters to the Editor   |   April 2008
Embrace Evidence...With Both Eyes Open
The Journal of the American Osteopathic Association, April 2008, Vol. 108, 190-191. doi:10.7556/jaoa.2008.108.4.190
The Journal of the American Osteopathic Association, April 2008, Vol. 108, 190-191. doi:10.7556/jaoa.2008.108.4.190
To the Editor:  
The August 2007 issue of JAOA—The Journal of the American Osteopathic Association, featuring six articles on evidence-based medicine (EBM), provides osteopathic physicians with a collection of tools for practicing EBM (2007;107:289-371). I am an evidence enthusiast, having published in the JAOA a systematic review revealing the inadequacy of the National Library of Medicine's PubMed database for collecting evidence regarding complementary and alternative medicine.1 In addition, my recent meta-analysis2 adapted methods used by the Cochrane Collaboration to present an innovative study of nonclinical data. Despite my enthusiasm for evidence, I would like to point out that there are a number of valid criticisms and concerns about EBM that the JAOA theme issue failed to raise. 
According to EBM, empirical evidence—especially that derived from randomized controlled clinical trials (RCTs)—is ranked as the best evidence on which to base a clinical decision.3-5 As a result, clinical experience and pathophysiologic rationales are relegated to subordinate positions. Yet, these “other ways of knowing” actually differ in kind—not in degree—from empirical evidence and do not belong on a graded hierarchy.3 Furthermore, a variety of hierarchies have been proposed by David L. Sackett, MD,4 Gordon H. Guyatt, MD,5 and other developers of EBM. Which one of these hierarchies is “best”? 
Dr Sackett4 has stated that EBM does not disregard the “...compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care.” Nevertheless, EBM guidelines have been hijacked by managed-care corporations as a rhetorical artifice for denying insurance coverage to patients when treatments are not yet fully supported by RCT evidence. My experience suggests that this misuse of EBM hamstrings physicians who use osteopathic manipulative treatment (OMT). 
Just this month, I was thrice denied reimbursement as a result of misuses of EBM. In these instances, the health maintenance organizations based their decisions on meta-analyses of chiropractic and physical therapy studies. The denials were signed by three osteopathic physicians—as if review by DOs somehow justifies the misapplication of these meta-analyses to OMT. 
Clinical decisions based on RCTs may not always be applicable to individual patients because RCTs are based on patient populations. The standard RCT protocol that excludes from study all subjects with comorbidities makes EBM least applicable to those patients who are most in need of clear evidence—those with chronic, complex illnesses.6 Physicians who rely on EBM but lack Dr Sackett's aforementioned patient-centered approach4 risk becoming regimented and reductionist—and certainly not holistic. Indeed, RCT-based decisions countertrend the emerging paradigm of individualized “molecular medicine.”7 
All six special communication articles in the August 2007 JAOA repeat the claim that the purpose of EBM is to enable physicians to practice the best medicine possible. If that is indeed its purpose, then EBM fails to meet its own imperative. There is no evidence, as defined by EBM (ie, RCTs), demonstrating that EBM actually improves patient care.8 
Advocates of EBM label it “objective” and “unbiased,” but EBM's reliance on scientific literature is inherently skewed by “publication bias”—that is, meta-analyses with “negative results” (ie, inconclusive findings that do not support particular agendas) are less likely to be published.9,10 Yet, systematic reviews with dramatic titles tend to be weaker methodologically.9 Evidence-based medicine may also be biased by money and power. A number of peer reviewers for the Cochrane Database of Systematic Reviews were recently found to have undisclosed financial ties to pharmaceutical corporations that led to ethical lapses in their reviews of RCTs.11 
Reliance on EBM canalizes clinical reasoning by structuring one's approach to finding answers, as well as one's approach to asking questions (eg, the PICO [patient population, intervention, comparison, outcomes] approach). Thus, there exists the danger of EBM becoming an institutionalized and authoritative “regime of truth.”12 Such a development runs contrary to the traditional outlook of osteopathic physicians, who have long opposed allopathic hegemony and long supported physician autonomy and medical pluralism. 
Evidence-based medicine can be interpreted as a medical philosophy—perhaps the first philosophical foundation to be adopted in allopathic medicine. However, osteopathic medicine already has its own longtime and well-known philosophical underpinnings.13 
Some medical professionals have described EBM as “outrageously exclusionary” and even “fascist.”12 Bernadine Healy, MD,14 former director of the National Institutes of Health, recently wrote, “By anointing only a small sliver of research as best evidence and discarding or devaluing physician judgment and more than 90 percent of the medical literature, patients are forced into a one-size-fits-all straitjacket.” 
In conclusion, osteopathic physicians should embrace EBM, but with common sense and with both eyes open—and without sacrificing our souls in the process. 
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Alderson P, Roberts I. Should journals publish systematic reviews that find no evidence to guide practice? Examples from injury research. BMJ. 2000;320:376-377. Available at: http://www.bmj.com/cgi/content/full/320/7231/376. Accessed December 16, 2007.
PLoS Medicine editors. Many reviews are systematic but some are more transparent and completely reported than others [editorial]. PLoS Medicine. 2007;4:e147. Available at: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0040147. Accessed December 16, 2007.
Cundiff DK. Evidence-based medicine and the Cochrane Collaboration on trial. Medscape Gen Med [serial online]. 2007;9(2):56. Available at: http://www.medscape.com/viewarticle/557263. Accessed December 10, 2007.
Holmes D, Murray SJ, Perron A, Rail G. Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. Int J Evid Based Healthc. 2006;4:180-186. Available at: http://www.ucl.ac.uk/Pharmacology/dc-bits/holmes-deconstruction-ebhc-06.pdf. Accessed December 10, 2007.
Rogers FJ, D'Alonzo GE Jr, Glover JC, Korr IM, Osborn GG, Patterson MM, et al. Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopath Assoc. 2002;102:63-65. Available at: http://www.jaoa.org/cgi/reprint/102/2/63. Accessed December 10, 2007.
Healy B. Who says what's best? US News & World Report. September 11, 2006. Available at: http://health.usnews.com/usnews/health/articles/060903/11healy.htm. Accessed December 10, 2007.