In July of 2009 I attended the Science-Based Medicine (SBM) Conference in Las Vegas. I was so impressed by what I learned that I volunteered to assist in any way that I could, and I have been a volunteer editor and handyman for ScienceBasedMedicine.org ever since. SBM is not a replacement for the more familiar concept of evidence-based medicine (EBM), but it does importantly emphasize some neglected aspects of EBM. This short article explains the differences.
What works? How do we know? History has shown that human “intuition” and the experience of doctors and patients are terrible ways to figure out which treatments are actually effective.1 Although science is far from perfect, careful experimental testing is by far the best way to find out if medicine or therapy works. Hooray for science! It’s the basis for every major medical advance in history.
Evidence-based medicine was founded as a named concept in 1990, but its spirit and principles go back to the 16th century, when Andreas Vesalius really got it rolling by — and this was kind of crazy at the time — actually checking anatomy instead of just taking some ancient Roman doctor’s word for it. It was a great idea, and it’s been delivering the goods so well ever since that many doctors have been a bit puzzled by the modern EBM movement: what else would you base medicine on? Faith? Tradition? Vehemence? (There are several amusing possibilities.2) For centuries, the whole idea of medicine has been to base it on the evidence. In theory.
Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to medical decision making. It seeks to assess the strength of evidence of the risks and benefits of treatments (including lack of treatment) and diagnostic tests.
Evidence-based medicine. Wikipedia.com.
EBM emerged as something that needed a manifesto and an acronym because, in practice — this is a bit awkward — an awful lot of medicine was still based on things like faith, tradition and vehemence, and not nearly as evidence-based as we’d like to hope. EBM was an upgrade — a clear, formal call for medicine to do better. It was an attempt to make what Vesalius started “official” (a few centuries late). Unfortunately, it may not be quite enough.
SBM is a refinement to EBM. The idea of emphasizing science in general instead of evidence in particular was first publicly proposed by Yale neurologist Dr. Steven Novella and infamous medical blogger and surgical oncologist Dr. David Gorski in early 2008, along with several other physician co-authors:
EBM is a vital and positive influence on the practice of medicine, but it has its limitations. Most relevant to this blog is the focus on evidence to the exclusion of scientific plausibility. The focus on evidence has its utility, but fails to properly deal with medical modalities that lie outside the scientific paradigm, or for which the scientific plausibility ranges from very little to nonexistent.
Announcing the Science-Based Medicine Blog, ScienceBasedMedicine.org contributors
EBM, although a step forward over prior dogma-based medical models, ultimately falls short of making medicine as effective as it can be. As currently practiced, EBM appears to worship clinical trial evidence above all else and nearly completely ignores basic science considerations, relegating them to the lowest form of evidence, lower than even small case series. This blind spot has directly contributed to the infiltration of quackery into academic medicine and so-called EBM …
Evidence-based medicine by definition rigorously limits itself to considering only the evidence. To an EBM purist, all that matters is testing. If a treatment works, it should pass scientific tests with flying colours. If it doesn’t, it won’t pass.
Sounds good. And don’t doctors and scientists already pretty much get that? Sure they do — most of them. But they aren’t the problem.
This EBM thing would work out great if no one was ever dishonest about the evidence. But snake oil is real, and snake oil salesman know full well that they can co-opt EBM simply by claiming that the evidence does support them, and/or that “more study” is needed. This has been called “pseudo-evidence based medicine” — quackery that tries to create the appearance of being evidence-based, “the practice of medicine based on falsehoods that are disseminated as truth.”3
When experts contradict this, the disagreement supposedly becomes a controversy — actually a manufactroversy.4
Thus the snake oil salesman leapfrogs right over awkward problems like whether their product is, say, consistent with the laws of physics. And so, sadly and strangely, the EBM movement has actually levelled the playing field for poor quality ideas — for which the evidence can be misinterpreted and misrepresented ad nauseum. Arguments about the quality and value of the evidence can drag on for years, ironically protecting the quack, who is virtually immune to the charge that the idea was never any good to begin with and that “further study” is a waste of time.
The classic absurd unintended consequence of EBM is that a really bad idea can easily be made to seem as though it is perpetually on the verge of legitimacy, no different than a much better idea that simply hasn’t yet been validated by research.
For instance, a quack selling sharp-stick-in-the-eye therapy could use pitch perfect EBM-speak to say technically correct but patently ridiculous things like this: “There is insufficient evidence to support the use of sharp sticks in the eye to treat blindness, so we should keep studying it!” Prominent EBM publications like The Cochrane Collaboration and The Natural Standard contain wonderful real-world examples: they routinely publish remarkably uncritical statements about therapies that have never yet had any evidence supporting them and — importantly — almost certainly never will.
This “quasi-scientific obfuscation” gives some amazingly bad ideas the appearance of far more legitimacy than they deserve, keeping them going like the Energizer bunny.
Physical and manual therapists are rarely inflicting harm on people’s bodies, but we’re probably doing something even worse: we’re using their bodies to justify our existence through myth propagation and quasi-scientific obfuscation.
John Ware, Physical Therapist, comment in an EBM vs. SBM debate
What does SBM have to say about sharp sticks in the eye? Simple: “That’s insane! Stop spending taxpayer dollars on studying something that stupid! There’s serious research that desperately needs funding and doing!”
There’s a tone of no-time-for-nonsense pragmatism in SBM, which I really like.
Extraordinary (implausible) claims require extraordinary evidence, and ignoring implausibility makes Carl Sagan turn in his grave. With its name, SBM suggests that we take basic science (much) more seriously when we’re talking about health care. We need to place greater emphasis on the value of a huge body of scientific knowledge about how humans work.5
The difference between SBM and EBM might seem like hair-splitting to many people. However, our civilization and tax dollars have better things to do than carry on studying and being distracted by low quality ideas in health care. Ironically, EBM has allowed extraordinary claims to cling to life without any evidence at all — not even ordinary evidence.
A science-based perspective is needed to address this problem.
I suspect that the originators of EBM … never thought of the possibility of EBM being applied to hypotheses as awe-inspiringly implausible as those of CAM. It simply never occurred to them; they probably assumed that any hypothesis that reaches a clinical trial stage must have good preclinical (i.e., basic science) evidence to support its efficacy.
EBM and SBM are not competitors. SBM is not intended to usurp EBM — just to emphasize some neglected and abused aspects of it. Was coining a new term the best way to do that? Does it undermine EBM? Should Drs. Novella and Gorski have just put their effort into fighting for better EBM? Maybe. I don’t know, and I don’t think it matters much. I think they are fighting for better EBM.
It is not that we are opposed to EBM, nor is it that we believe EBM and SBM to be mutually exclusive. On the contrary: EBM is currently a subset of SBM, because EBM by itself is incomplete. We eagerly await the time that EBM considers all the evidence and will have finally earned its name. When that happens, the two terms will be interchangeable.
Jacqueline: EBM ought to be Synonymous with SBM, Dr. Kimball Atwood
This is a listing of most of the articles at ScienceBasedMedicine.org that address the idea of SBM and the reasons for the existence of the blog, in the order that they have appeared. The ScienceBasedMedicine.org about page also has an excellent short summary … which I wrote (cribbing from articles written by Drs. Novella, Atwood, and Gorski).
BACK TO TEXT
[Pseudo-evidence based medicine] is the practice of medicine based on falsehoods that are disseminated as truth. Falsehoods result from corrupted evidence — evidence that has been suppressed, contrived from purposely biased science, or that has been manipulated and/or falsified, then published. Or falsehoods may result from corrupted dissemination of otherwise valid evidence. These falsehoods, when consumed as truth by unwitting and well-intentioned practitioners of evidence-based medicine, then disseminated and adopted as routine practice, may well result not only in inappropriate quality standards and processes of care, but also in harms to patients.