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Tarnished Gold: The Sickness of Evidence-Based Medicine

Tarnished Gold: The Sickness of Evidence-Based Medicine by Steve Hickey and Hilary Roberts. Create Space; 2011. Paperback, 342 pages. ISBN: 978-1466397293. $39.95.

This is a remarkable book that, in the tradition of Thomas Kuhn’s groundbreaking Structure of Scientific Revolutions (1962), provides important tools to help one understand how data become useful information (or not) in improving our understanding of nature and human biology and in guiding medical practice.

Originally conceived as a post-WWII cost-saving strategy for the UK National Health Service, by the 1990s, evidence-based medicine (EBM) was becoming the latest fashion in medical science. The authors make a convincing argument that it has become, in fact, a cloak for establishing credibility and “scientific high ground” by statisticians who lack a working understanding of what my faculty advisor, Nobel Laureate Baruch Blumberg, liked to call “biological plausibility,” and, in turn, by physicians intimidated by elaborate uses of statistics. Further, the authors argue that EBM has become a superficial marketing slogan for respectability of costly big pharma and “big science” projects, which increasingly crowd out other valid kinds of experimentation, observation, and research. This problem will be painfully familiar to anyone working in the fields of natural medicine, nutritional medicine, complementary or alternative medicine, integrative medicine, etc. The human biological paradigm, model, or theory underlying any scientific approach and medical practice may differ, but it is important to have one in order to develop any sense of the plausibility for assigning a statistical association to having an actual role in the causation of health or disease.

The authors expose the fascinating and troubling tale about the politicization and massive government intervention into the scientific process for “proving” that smoking is the cause of lung cancer. They argue that this unprecedented government intervention set a different, more legalistic standard for how scientific data are translated into information about human biology to help guide public health and medical practices. Despite the body of evidence linking heavy smoking to lung cancer, this process leaves behind a lot of valid information about genetic and other risk factors and the fact that many non-smokers still get lung cancer. The smoking and lung cancer precedent also helped create a role for government and industry bureaucrats in using statistics to force social agendas onto public health and medical practices. They argue that the diversity among patients and circumstances (a critical component of holistic, complementary or alternative, and integrative medical practices) is lost and replaced by arbitrary and illusory standards that in fact represent nothing.

Additionally, the authors show that the modern preoccupation with statistical manipulations forcing every observation into an arbitrary placebo-controlled clinical trial — and now “evidence-based” medicine — has left physicians and scientists in the dark and half-blind to critical observations from the daily realities of clinical practice, as well as understanding basic biological sciences and how nature operates in the universe. Therefore, calling such approaches a “gold standard” in medical research is limiting and counter-productive and undermines true scientific innovation. Thus, the title of the book: Tarnished Gold.

The book is full of colorful and illuminating quotations from notable characters in science. One of the shortest and my personal favorites is by Nobel Laureate Ernest Rutherford: “If you need a statistician, then you should design a better experiment.” The authors present several issues that are critical to understanding the limitations of the information gained from EBM, including the following:

  • The information that is lost about individual patients in conducting statistical studies;
  • The huge bias in what research gets funded and the kinds of questions asked (and not asked);
  • The reductionist, hierarchical approach to what constitutes evidence;
  • Withholding results due to corporate ownership of data;
  • Publication bias where only certain kinds of data get published due to decisions by researchers, authors, editors, and reviewers;
  • Medicalization of human biology whereby new diseases are continually being discovered; and
  • Disreputable statistical analyses, including deliberate cheating, fraud, and misrepresentation in up to half of the scientific literature due to academic careerist and funding pressures (according to The New York Times, April 2012).

The authors conclude that EBM is “junk science” and there is little, if any, prospect for a rational defense of its methods. They argue that EBM harms patients and suppresses true medical innovation and progress. They also argue for patient-based rather than evidence-based medicine. This should be particularly evident to those familiar with natural medicine where the theories, methods, funding, and authority are all stacked against it. Fortunately, the average patient and physician may not be concerned with all these considerations but only with what works, that is, “good medicine.” To which it might be added, as taught by my then-medical school professor and eventual US Surgeon General, C. Everett Koop, “The least medicine that works is the best medicine.” And, per Lord Rutherford, the fewer statistics needed to reach a conclusion, the better.

—Marc S. Micozzi, MD, PhD Adjunct Professor Georgetown University School of Medicine Washington, DC