Evidence isn’t Everything: A Doctor Says We Must Go Beyond Science

On EDGE | Opinion

A recent, controversial opinion piece we published argued that a local event gave too much credence to “unscientific” medical practices. In response, a conventionally trained Yellowknife doctor suggests that no one has a monopoly on healing.

Medical practitioners of all stripes — complementary or conventional — must grapple with the same fundamental question: does a particular treatment work? Ultimately, people want to know whether a treatment will work for them — whether it will help them to live longer, feel better, or regain other measures of health — and often we can’t answer this question. A great deal of western medicine relies on imperfect data and common sense (or clinical judgment).

What’s the proof?

The central question hinted at by the previous article is: how do we know that a treatment objectively accomplishes some sort of physiological goal? Conventional western medicine has developed a tool to address this question: the randomized, double-blind, placebo-controlled clinical trial, fondly known as the RCT. But many well-known staples of conventional medicine have never actually gone through a RCT. We have to accept their benefits despite a lack of evidence that meets modern standards.

Why? For one thing, RCTs are incredibly expensive. An RCT involves a lot of people, and a lot of money. It requires two large groups of patients, one of whom receives the actual treatment, while the other receives either a placebo that they and their doctor think might be the actual treatment, or the usual “standard” treatment, to which the new treatment is being compared. The two populations are as similar as possible, and lots of parameters (from blood pressure to tumour size to various measures of pain and happiness) are measured before, during and after the treatment to find out if it provided any benefit.

If this is done late in the development of a new drug, and the drug does not achieve its pre-determined outcomes, it often dies an early death and never makes it to consumers; it will be especially hard to market in this country, since unproven claims are not allowed by Health Canada. This policy has probably served to protect many from ineffective and dangerous treatments. However, it applies to physician-prescribed substances and not natural products — a source of discomfort for many people who doubt the claims of complementary treatments.

As a result, the RCT has become the standard by which new treatments are measured, particularly if we wish to be practicing “evidence-based medicine.” Evidence-based medicine was the holy grail during my training, and we always discussed in detail how the evidence available related to a particular patient’s situation.

Evidence is a double-edged sword

The RCT has humbled physicians by frequently demonstrating that therapies we had thought made sense simply don’t provide significant benefit to people. As a medical specialist, part of my role is to help patients and general practitioners understand which set of guidelines, or which data set, is most relevant given the complexities of an individual’s health needs. However, evidence-based medicine has some drawbacks.

First, many of the conventional therapies we offer have not actually been widely tested and would not hold up to the standard of evidence demanded of new therapies today. This list would probably include major items such as Caesarean section for obstructed labour; antibiotics in life-threatening infection; insulin for type 1 diabetes; and anaesthesia of some sort for people undergoing major surgery. In many cases, early data was so compelling that a randomized trial would have been unethical — depriving some people of what was clearly effective and life-saving therapy. And some of these therapies were developed before anyone had thought of doing large-scale RCT’s.

Second, there is not a lot of room for individual experience in the RCT. Placebo effect (meaning how much benefit a person has simply by thinking they are receiving treatment) is a substantial factor in a lot of conventional medicine — perhaps up to 20-25 percent in some cases. And the value of therapeutic relationship — in which a person trusts that a practitioner is on their side and will help them achieve a more complete state of health — cannot be overstated.

Truth in experience

Perhaps, in seeking evidence-based medicine, we have sometimes lost the ability to accompany a person through their illness — a skill that was foundational in medicine before the antibiotic era. We have become focused on diagnosis, curative treatment and best available medical therapy — partly because we thought that’s what people wanted from us, and partly because we truly believe that evidence-based medicine is able to find the truth in a way that experience, logic and anecdote cannot.

Some people need, more than anything, someone to accompany them, touch them, listen to their concerns, and offer them a therapy that they have faith in — perhaps because thousands of people over many centuries have sworn by it. Others just really need their appendix removed, their heart attack diagnosed, a better insulin regimen, or a few days on a ventilator. My sense is that in more and more circumstances, different stripes of practitioners are willing to identify the limits of their own practice and suggest other approaches when their skill set cannot address the most pressing issues. None of us has a monopoly on healing.

Opinion

YKU

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