Wednesday, August 23, 2006

The Post-Modernist View: Evidence-Based Medicine as Fascism?

As many of you realize, I am an advocate of evidence-based medicine (EBM), roughly defined as medicine based on critical review of the best availalble evidence from clinical research, combined with clinical judgment, knowledge of biology, and patients' values and preferences. (See also: "Evidence-Based Medicine: What It Is and What It Isn't" from the 1996 British Medical Journal for a better explanation.)

Some of us who advocate EBM see it as an antidote to health care based on dogma, ideology, or commercial interest.

Unfortunately, although EBM has generated a lot of enthuisiasm among its advocates, it has been a hard sell in the larger health care world. I have always suspected one reason for this is that EBM potentially challenges ideas, programs, and products in which people believe, or in which people have vested interests. If you really believe gizmo X works, or if you make a lot of money selling gizmo X, you may not be enthused about a rigorous review of the evidence that suggests that maybe gizmo X doesn't work so well.

In any case, by 2002, only about one-third of US and Canadian internal medicine residencies included any time for EBM (Hatala R, Guyatt G. Evaluating the teaching of evidence-based medicine. JAMA 2002; 288: 1110-1111.) In 2004, "now most medical programmes in the United States attempt to teach EBM, although few succeed...." ( Del Mar C, Glasziou P, Mayer D. Teaching evidence based medicine: should be integrated into current clinical scenarios. Brit Med J 2004; 329: 989-990.)

Thus my jaw dropped when I saw an article entitled "Deconstructing the evidence-based discourse in health sciences: truth, power and fascism." (Full citation: 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.) This article has already created quite a bit of buzz among those who are skeptical about post-modernism, and those who advocate for EBM, i.e., people like me.

The paper is written in the usual turgid post-modernist style, with all the expected bowing and scraping to Foucault, Derrida, Lyotard, Deleuze, Guttari, etc, the tortured sentence structures, and the obscure ("interpellated"), and sometimes apparently made-up words ("hysterisation").

The paper includes some almost hilarious accusations. As noted above, providing effective teaching of EBM in medical schools and post-graduate medical education has been difficult. In medical schools that I have seen, EBM advocates are a minority, sometimes embattled. Yet Holmes et al accuse EBM of being so powerful that "in a number of faculties of health sciences ... the dominant paradigm of EBHS [evidence-based health science] has achieved hegemony." Moreover, according to Holmes et al,

Rather than risk being alienated from their colleagues, many scientists find themselves interpellated by hegemonic discourses and come to disregard all others. Unfortunately,privileging a single discourse (evidence-based medicine (EBM)) situated within a single scientific paradigm (postpositivism) confines the researcher to a yoke of exactly reproducing the established order. To a large degree, the dominant discourse represents the ladder of success in academic and research milieus where it establishes itself as a weapon used against those who praise the freedom of scientific inquiry and the free debate of ideas.
Say what? I'm sure all those who struggled to get a few hours of EBM instruction into about one-third of internal medicine residencies by 2002 will be gratified to know that they are supposed to be on "the ladder of success in academic and research mileius." The notion that someone thinks EBM has been used to suppress free speech is just plain mind-boggling, although post-modernism has certainly been used to justify the suppression of free speech. (See, for example, the title essay in There's No Such Thing as Free Speech, and It's a Good Thing, Too by Stanley Fish.)

If anyone knows of such an institution, please tell me about it so I can apply there for a job.

Holmes et al also asserted that EBM advocates get "institutional promotions and accolades, public recognition, and state contracts of all kinds." Huh? Boy, I sure have missed out, and so have many of my friends and colleagues. At least in the US, EBM has not exactly been high on the priority list for federal government funding. (To add further irony, the article by Holmes at al was funded by one of those "state contracts of all kinds." Their paper was funded by the Canadian government, through the Canadian Institutes of Health Research- Institute of Gender and Health.)

But the paper goes from hilarious to nasty (which is why I don't believe that it was a hoax or a parody). The paper literally accuses advocates of evidence based health of being fascists,
Drawing in part on the work of the late French philosophers Deleuze and Guattari, the objective of this paper is to demonstrate that the evidence-based movement in the
health sciences is outrageously exclusionary and dangerously normative with regards to scientific knowledge
. As such, we assert that the evidence-based movement in health sciences constitutes a good example of microfascism at play in the contemporary scientific arena. The philosophical work of Deleuze and Guattari1 proves to be useful in showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm – that of post-positivism – but also and foremost in showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure.
Them's close to fightin' words.

Holmes and colleagues then specifically accuse the Cochrane Collaboration of being a fascist organization,
The classification of scientific evidence as proposed by the Cochrane Group thus constitutes not only a powerful mechanism of exclusion for some types of knowledge, it also acts as an organising structure for knowledge and a mechanism of ideological reinforcement for the dominant scientific paradigm. In that sense, it obeys a fascist logic.
Fascism is not too strong a word because the exclusion of knowledge ensembles relies on a process that is saturated by ideology and intolerance regarding other ways of knowing.
To get more of tthe flavor of Holmes and colleagues arguments,
A starting point for health sciences would be to promote the multiplicity of what Foucault describes as subjugated forms of knowledge (savoirs assujettis): these forms of knowledge are ways of understanding the world that are ‘disqualified as non-conceptual knowledges, as insufficiently elaborated knowledges: naïve knowledges, hierarchically inferior knowledges, [and] knowledges that are below the required level of erudition or scientificity’ These forms of knowledge arise from below, as it were, in contradistinction to the top-down approach that characterises the hegemonic thrust of EBHS. For Foucault, a subjugated knowledge is not the same thing as ‘common sense’. Instead, it is ‘a particular knowledge, a knowledge that is
local, regional, or differential’

In our view, this positive process begins with a critique of EBHS and its hegemonic norms. As we have argued, according to postmodern authors, these norms institute a hidden political agenda through the very language and technologies deployed in the name of ‘truth’. Again, Foucault sums up this position in his critique of modern medicine: ‘Medicine, as a general technique of health even more than as a service to the sick or an art of cures, assumes an increasingly important place in the administrative system and the machinery of power’ Here, in such an ‘administrative system’ and a ‘machinery of power’, we find a classic allusion to what Hannah Arendt defines as totalitarianism or fascism, as we defined it earlier.
That should make Hannah Arendt, a true foe of totalitarianism, spin in her grave.

Finally, Holmes et al compared the language of EBM with "Newspeak" in 1984. I invite readers to read the article by Holmes et al, compare it to some article that is reasonably typical of those that advocate for EBM (such as the one from the 1996 BMJ linked above) and decide which is more like Newspeak.

The pity is that post-modernism's word-play mumbo jumbo and its cults of personality seem to be a great way for academic institutions to distract themselves from what is really going wrong with health care, the real threats to our professional values of the sort we have documented on Health Care Renewal.

Recovering from the brain fever induced by reading about "colonised (territorialised) science," "regimes of knowledge," "interpellated academics," and the "hysterisation of the female body," one might speculate: Has post-modernism been deliberately encouraged by some academic leaders, possibly those with the most severe conflicts of interest, to distract us from concentration and abuse of power in health care, the pervasiveness of conflicts of interests in health care organizations, and unethical and even illegal behavior by health care leaders?

If so, it's working.

ADDENDUM (25 August, 2006). See also the commentary in the Guardian (UK) by Ben Goldacre.


james gaulte said...

I tried to plow through that article and came away wondering what the heck the "hidden political agenda" is that the authors warned us about.

Anne Gill said...

The following is Archie Cochranes War Record his decendents should seriously consider suing the authors of this ridiculous article.

1936 : International Brigade, Spanish Civil War.
1939-46 : Captain, Royal Army Medical Corps.
1941 : Taken prisoner of war in June 1941 in Crete; PoW medical officer in Salonika (Greece) and Hildburghausen, Elsterhorst and Wittenberg an der Elbe (Germany).

We are now in another war between reason and unreason!

Anonymous said...

". I have always suspected one reason for this is that EBM potentially challenges ideas, programs, and products in which people believe, or in which people have vested interests. If you really believe gizmo X works, or if you make a lot of money selling gizmo X, you may not be enthused about a rigorous review of the evidence that suggests that maybe gizmo X doesn't work so well."

This is a stretch on my part to bring up two recent WSJ articles.

The popular press has recently put forth a number of articles regarding weight. How 2/3 of Americans are obese and how just a few pounds will have a negative impact on health and life span. My understanding is that the current weight charts incorporated third world data, and that starvation diets do not lengthen life.

The August 22 WSJ has an interesting article A New Breed of Diet Medications by Elizabeth Bernstein. The jest of the article is the use of off-label drugs for weight loss and the risk associated with their use.

We find this quote "Obesity is a chronic disease-diet and exercise aren't enough for long-term weight loss for most patients. Says Robert Skversky, a baristric physician in Newport Beach Calif. Chronic diseases need drugs to keep them under control."

Some of the drugs in question are: Adderail XR whose sales increased more than 3,000% between 2001 and 2005. Sales of Provigil increased more than 360% per IMS health. Sales of Welbutrin XL were $1.4B or a 1000% increase since it's introduction in 2003. Other drugs in the mix were Topomax and Byetta.

All of these are serious medications, some with black box warnings, others with serious side effects or the potential for addiction.

This was followed on August 23 by Armed With New Vaccines, Drug Makers Target Teenagers by Jeanne Whalen.

This article can best be summed up by "The adolescent area is.. an area of tremendous growth opportunity.." Wayne Pisano, Sanofi Pasteur. The article then outlines efforts to get parents and doctors on the side of continued vaccinations for their teen children. All in the name of good health and a potentially $19B market by 2010.

Sanofi has high hope for it's product Menacrta. David Williams chief executive stated "One of the biggest things we do is work with the policy making community. Knowing who the influential people are is part of our marketing." Sales of this drug were $215M it's first year with project sales of $1B when marketed worldwide.

Merck is pushing Gardasil to state legislatures. Per Mark Feinberg they find this to be a "successful approach "All of the vaccine makers are promoting their vaccines to the CDC and AAP.

Weight and childhood disease are serious issues. I am not a doctor and cannot argue the medical issues. I am concerned that "new" data always shows a large population in need of any given drug.

What I can question is the increase off-label use of drugs and pharm's support of this use. These sales increases have not gone unnoticed. Remember pharma is not libel when their drugs are used in this manner.

I can also question pharma going to the legislature to mandate their drugs. I can see this as cheaper than marketing to the general population, but is this what we want? Pharma makes money. The legislator gets a nice contribution, and we the public, pay for this through higher taxes or insurance premiums.

EBM will fight for acceptance as long as there are financial interest who see it's defeat in their best interest.

Steve Lucas

Fred Goldstein said...

I remember a conversation with my father, an Infectious Diseases specialist and Professor of Medicine who been active in the HIV/AIDS arena with a clinic and conducting research. After a particularly rough day of being hammered by physicians regarding my discussion of EBM and Guidelines and the cookbook nature of these approaches; I called him for consolation. During the conversation I asked him if he still used the DHHS Guidelines for the management of persons with HIV/AIDS He said "of course". I asked why, as he was an acknowledged expert with over 20 years of caring for people with this disease. He said "If I didn't, I would ultimately discover the known."

Now not every physician will discover the known, and even if they did, how long would it take and what would be the cost to those treated before they got there?

Matthew Holt said...

Oh, come one no-one ever takes the Quebecois seriously (at least I hope not!)

Anonymous said...

I would agree that this article is not a hoax, but a serious postmodern stab at the Evidence Based Medicine movement. I'd critique the article for not explaining its terms for those not in the post-structuralist fan club.

Much of the authors' theoretical language comes across as "ossifying" and "hegemonic" in its own right. It is rarefied and yet absolutely typical of many cultural studies papers you might read over the past several decades. You just can't seem to get away from the Deleuze-Guattari-Foucault-Derrida critique. These theorists seem to be used like prophets or saints, to be invoked at the mere whiff of any claims to "truth."

Where is the consideration that EBM is a well-intentioned effort to save lives, open to many "voices"? We can't deny that research data must remain open to criticism with the well-established tools of biostats and the scientific method.

That being said, as a psychiatrist, I can speak to the assault on validity of lesser-researched therapies, like psychotherapy, that has occured with the advent of EBM. The inexorable pull of pharmacotherapy on the field of mental health likely has resulted in a demeaning of the psychotherapy literature. This is an unfortunate trend in the field and an ongoing concern.

Ken Thompson said...

well well well, another body blow to post modernism by the ebm crowd... its interesting that the last and only time i (a life long democratic socialist) have been called a fascist was by folks who didn't like my objection to the narrow scientism of ebm. now the post modernists have returned the favor. all these accusations seem to ignore the evidence and the spirit of what is being said.

but before blood starts to boil, lets take a look at where we are. I am hearing that EBM advocates are having a hard time getting the powers to be to change. i know that pm folks say the same. I am seeing in this post daily evidence of the use of money and power to corrupt health care-both science and its practice. i see some pm folks dismissing any science efforts as tyranical. i also see some people advocating ebm in a taylorist paradigm of efficiency that rejects the individual personhood of patients- the overriding focus on biomedical interventions in psychiatry is one example. and i see consumers of health care services objecting on a daily basis to the pursuit of research and knowledge by physicians that does not include their voice in its design and application.

Maybe, just maybe, roy, you are right. perhaps the issue at the core here is the exercise of power over others. from what i am reading both camps- those in EBM and those in PM recognize this. and the powers that be have figured out how to keep us from focusing on them and working out our differences.

someone suggested that the battle is between reason and unreason. i would like to suggest that the battle should be against power over people. we must learn to reconcile reason and passion in that fight. reason alone does not have the vision to sustain the fight, and passion alone can't find the vulnerable spots. i don't want a world with the capitalists in charge, nor do i want a world with the scientists in charge, or one where the academic intellectuals rule! rather, we need to create a world of many more participating voices.

how to help that happen? in psychiatry, there is a new movement (the recovery movement) working now to construct a science and a practice which recognizes complexity and incorporates many voices in its production, dissemination and implementation.

Ken Thompson

Harold Lehmann said...

The true "body blow" has to do with the very nature of evidence...What would happen to post-modernism if we applied our tools to their "discourse"? What would we say about the evidential (epistemologic) status of comments by philosophers (of any country)? I am afraid that most of their discussions would settle down at Level D or X. (Isn't most of philosophy, when they appeal to empirical fact, mere anecodote?)

On the other hand, this very blog addresses head on the very forces this article warns us about, and those of us fighting for a piece of the curriculum action know very well that a lot of mischief uses "EBM" as political cover. Is that fascism? Perhaps "kleptocracy" is closer to the bone....

Anonymous said...

EBM is simply a tool. If you buy the notion (and I do) that EBM consists of the best available evidence informed by clinical judgment, then we are in the arena of good individual physicians who are well read and apply their professional and research knowledge to improve the quality of health for their patients. If so, then what is the debate? This is an unarguable good for physicians and patients everywhere. But if you look at the role that EBM plays in the centralization of decision making such that the decision moves from the physician to a centralized guidelines committee see how this folds in the arena of managed care (desire to control and predict costs through centralized decision making) and the desire of drug manufacturers to sway markets through guidelines, then the issue really is about centralized power. EBM is a tool for centralizing power. When you have read conflicting sets of evidence based guidelines, then you see the tool in action and the issue is centralized power and who is at the helm. This means the guidelines committee composition becomes the determinant of the question framed, the evidence selected, and the conclusions drawn from that evidence. Biased committee panels (whether through commercial interests, dogmatic viewpoints, academic research territorial marking), select and intepret evidence through the filter of their own biases. Hence, evidence based medicine is not a panacea for corruption, dogma, or the influence of commercial interests.

When you think about it, the drug companies actually have more controlled studies (at least for their on-label usage) than other well-established forms of medicine (surgery, for instance). The bigger ethical dilemna is posed when there are no controlled trials supporting a treatment regime and patients are suffering. It could take decades, centuries to establish a base of treatment approaches through controlled trials. One study points to the statistical futility of trying to solve medical treatment issues solely through controlled trials. (We are talking life-times.) Saver JL Kalafut M, Combination therapies and the theoretical limits of evidence-based medicine. Neuroepidemiology, 2001; 20(2): 57-64.

Innovation, in the form of individual physicians trying to help their patients frequently lead to more focused clinical trials. Yet the role of clinical innovation is suppressed in clinical guidelines that restrict the exercise of clinical judgment. Moreover, insurance companies have heavily promoted evidence based medicine and now use it as a basis for denying patient care. (They will not cover treatment x until there are controlled trials.) When you consider the fact that controlled trials were introduced in the 50' and that the bulk of medicine practiced even today is not evidence base, what do we propose to do with the evidence gap? Setting the evidence bar too high hurts patients, suppresses innovation, and enriches insurers. Until evidence is developed, physicians must be free to use their discretion.

In addition, it should be borne in mind that controlled trials are not necessarily the best evidence because their results may not translate to clinical patient population (due to entry control requirements etc.) Moreover, approaches that work for 80% of the population do not work for 20%. Patients are not statistical norms.

It is probably impossible to form an unbiased panel to evaluate evidence--given all of the opinion leaders who serve on these panels. It helps if the panel is ad-hoc (as opposed to a specialty society representing one viewpoint) and if different stakeholders viewpoints are represented. This helps keep people honest in the selection and interpretation of evidence. When the science is lacking, the answer should not be a default to no treatment, but a default to the exercise of clinical judgment so that the type of innovation that leads to solutions can occur.