Why “Science”-Based Instead of “Evidence”-Based?

A short essay summarizing the rationale for the science-based medicine movement

by Paul Ingraham, Vancouver, Canada MORE
close
Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

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 with the SBM “movement” in any way that I could, and I have been a volunteer editor at Science-Based Medicine ever since. SBM is not a replacement for the more familiar concept of evidence-based medicine (EBM), but it does importantly emphasize something that has become a neglected aspect of EBM. This short article explains the difference.

First, a thumbnail sketch of EBM

What works? How do we know? History has shown that human intuition and the experience of health care professionals are terrible ways to figure out which treatments and therapies actually make people healthier. Although science is far from perfect, careful experimental testing is by far the best way to find out if a treatment actually works. Hooray for science! It’s the basis for every single major medical advance in the last hundred years.

Evidence-based medicine was founded as a named concept in 1990, though its principles go back much further.

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.

So why SBM? Doesn’t EBM already have this gig?

The idea of emphasizing science 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

Hijacked! How quacks use EBM to their own advantage

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. 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.

When experts protest, it simply becomes “controversial” — a manufactroversy.1

Thus the snake oil salesman leapfrogs right over the whole awkward question of whether or not 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 immune to the charge that the idea was never any good to begin with and that “further study” is a waste of time.

Unintended consequences

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 EBM-speak to say: “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 examples: they routinely publish remarkably uncritical statements about therapies that have never yet had any evidence supporting them and probably never will.

This gives them the appearance of far more legitimacy than they deserve.

Enter the science

What does SBM have to say about sharp sticks in the eye? Simple: “That’s insane! Stop spending taxpayer dollars on studying the therapeutic efficacy of sharp sticks in the eye! There’s real work to do in medicine!”

There’s a certain no-time-for-nonsense pragmatism to SBM (which I really like).

Extraordinary (implausible) claims require extraordinary evidence, and ignoring implausibility causes Carl Sagan to 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.2

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.

No contest

EBM and SBM are friends, partners. It’s not a contest. SM is not intended to usurp EBM — just to emphasize an aspect 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.

Notes

This is partly a phenomenon of the Information Age. These days anything can be “controversial.” You can pretty much make up the craziest thing you can think of and make it controversial just by announcing it and responding to any objections by demanding that your point of view get equal time. That’s exactly how bizarre many modern so-called controversies are. A lovely legacy of political correctness. Return to text.
“Scientists always turn out to be wrong!” This is a common protest, but it ignores the obvious truth that much of what we know is never going to be over-turned. The Earth really is round: I absolutely guarantee that you aren’t ever going to wake up to headlines saying, “Scientists wrong! Earth Actually a Cube!” Similarly, much of medicine is pretty much carved in stone now — you can take that to the bank. Of course there are still mysteries, but that doesn’t mean you want your tax dollars spent on researching something that is totally at odds with gigantic hunks of well-established knowledge. Return to text.