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

The rationale for making medicine more science-based

2,300 words, updated May 17th, 2014
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

Science-based medicine (SBM) is not a replacement for the more familiar concept of evidence-based medicine (EBM). Instead, it emphasizes some neglected aspects of EBM. This article explains the differences and the need for the distinction.

A thumbnail sketch of EBM

What works? How do we know? History has shown that human “intuition” and the experience of doctors and patients are awful 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 radical 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.

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

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 …

“Hard science” and medical school, Dr. David Gorski

Hijacked! How quacks use EBM

Evidence-based medicine was once mocked in a classic article for the British Medical Journal, which pointed out that “the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials.”3 EBM isn’t actually that foolish in theory. Good testing is extremely important, but only one part of a complex puzzle, and good doctors and scientists know this perfectly well, and always have.

But they aren’t the problem.

In practice, EBM richly deserved the satire, because it has often been applied simplistically and overzealously, as though all that matters is the results of trials. And that, bizarrely, created a marvelous opportunity for quacks…

This EBM idea, even applied too narrowly, would have worked out pretty well if no one had ever been dishonest about the evidence. Snake oil is real, and snake oil salesman have savvily co-opted EBM just by claiming that the evidence does support them.But snake oil is real, and snake oil salesman have savvily co-opted EBM just by claiming that the evidence does support them, and/or that “more study” is needed. They can actually seem more EBM-ish by rejecting any consideration other than their (distorted) evidence. This has been called “pseudo-evidence based medicine” — quackery that strives to create the appearance of being evidence-based, “the practice of medicine based on falsehoods that are disseminated as truth.”4

When experts challenge it, the disagreement supposedly becomes a “scientific” controversy — actually a manufactroversy.5

Thus the quack 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 accidentally levelled the playing field for poor quality ideas — oops! Now 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.

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 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

Enter the science

What would Carl Sagan do? Always a good question.

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.6

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.

Answering a criticism of science-based medicine, Dr. David Gorski

No contest

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.

Yes, Jacqueline: EBM ought to be Synonymous with SBM, Dr. Kimball Atwood

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Notes

  1. “Like bleeding, doctors' intuition was a central part of medical practice until it was categorically proven not to offer patients the best outcomes. This led to the birth of evidence-based medicine.” — From ‘trust us, we’re doctors’ to the rise of evidence-based medicine, Bradley (theconversation.edu.au) BACK TO TEXT
  2. Isaacs et al. Seven alternatives to evidence-based medicine. The Oncologist. 2001. PubMed #11524559. BACK TO TEXT
  3. Smith et al. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. British Medical Journal. 2003. PubMed #14684649. BACK TO TEXT
  4. Smith. Pseudoevidence-based medicine: what it is, and what to do about it. Clinical Governance: An International Journal. 2007.

    [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.

    BACK TO TEXT
  5. 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. BACK TO TEXT
  6. “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. BACK TO TEXT