The Rise and Fall of Evidence Based Medicine (1998) [pdf] • Hacker News Board

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#51

Post by haldujai » Thu, Jun 01, 2023, 10:40 PM UTC

jbandela1 wrote: post #15

Evidence Based Medicine is one of those things that is a good thing, but was pushed so hard by its proponents that it ended up overemphasizing a particular kind of study as the only real way to know things in medicine. Yes, absolutely, medicine should be evidence based. Yes, large randomized, double blind, placebo controlled studies provide a lot of information. However, there are limitations with these kinds of stud…

I think of EBM as "where stronger evidence exists it trumps expert opinion" (almost all of the time). In other words, go down the hierarchy[0].

> I worked with physicians who would examine and talk with a patient and tell me that something is not right and to do more extensive tests which would end up unearthing a hidden infection or other problem that we were able to treat before it caused major problems.

Accordingly I don't view this as discordant with an evidence based medicine practice as you're not practicing in an area with clinical-trial evidence (and notably, expert opinion is evidence albeit weak). If you told me you did routine urinalysis and blood cultures on all your admissions I would view that as discordant and incorrect practice, regardless if expert dinosaur feels it saves lives in their experience.

I also view EBM as opposed to "science-based medicine". Just because something has a (theoretical) scientific basis it does not meet the standard to enter my routine practice, I need stronger evidence for that which notably does not have to be in the form of a RCT as you suggest[0].

> How to apply the results of the large study to the individual patient in front of you is still more of an art than a science.

Frankly, the practice of medicine is more art than science and EBM is a guiding principle that keeps us grounded to measurable outcomes.

[0] https://en.wikipedia.org/wiki/Hierarchy_of_evidence

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#52

Post by haldujai » Thu, Jun 01, 2023, 10:46 PM UTC

bjornsing wrote: post #39

The main flaw in EBM is that it inverts the scientific method: It’s no longer about hypotheses and falsification. Instead it’s about “scientifically proven facts” (aka “evidence”). Sadly this aligns much better with our dogmatic instinctive understanding of knowledge as a set of agreed truths.

It's because medicine is as much an art as a science given the impossibility of problem space, also whenever we ignore evidence we end up harming/killing people.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#53

Post by rgbgraph » Thu, Jun 01, 2023, 10:48 PM UTC

importantbrian wrote: post #48

rgbgraph wrote: post #30

There was a great book about Evidence Based Medicine, from a woman out of Oxford, I read a long while ago. Can't for the life of me remember the name, but Oxford does have a center for "Evidence Based Medicine," and the whole idea has been slowly coming back into fashion. Instead, all I can recommend is a collection of essays -- loosely -- related to the subject: Where's the Evidence? , Silverman --- On another note,…

What makes you conclude that statins are "bunkum"? I don't know anything about anti-depressants or surgical implants, but I have gone down the rabbit hole on statins and at least as far as I can tell they do what they are generally claimed to do, are safe, and so if you are at high risk for hear disease you should probably be taking them.

In bullet-points:

- Absolute risk reduction in CVD-caused mortality is mild at best (- Percentage of people that get side-effects is higher than the percentage of people that receive a benefit from statins; as well, the side-effects are rather serious in affecting QoL -- making them a poor choice as a long-term prophylactic

- Generic lipid panels that the vast majority of people take are generally worthless for estimating lipid health: LDL "large particle -- bad" cholesterol is not actually measured, but estimated. The current formula is: (total cholesterol - HDL - triglycerides)/5 which is liable to under-report true LDL levels. Estimation also has the drawback of being unable to tell how much of each "bad" particle is actually in your blood (chylomicrons vs VLDL vs LDL etc.) -- muddying your actual risk profile. Likewise, no LDL "content" tests are performed to measure how much cholesterol each LDL is actually carrying. So yes, statins will lower these numbers, but the methodology around these numbers is flawed, and only loosely correlated with cardiovascular health

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#54

Post by nradov » Thu, Jun 01, 2023, 10:54 PM UTC

jbandela1 wrote: post #15

Evidence Based Medicine is one of those things that is a good thing, but was pushed so hard by its proponents that it ended up overemphasizing a particular kind of study as the only real way to know things in medicine. Yes, absolutely, medicine should be evidence based. Yes, large randomized, double blind, placebo controlled studies provide a lot of information. However, there are limitations with these kinds of stud…

This is a central point in the new book Outlive by Dr. Peter Attia. RCTs are great, but realistically we're never going to have long-term RCTs that give clear evidence on prevention of the chronic diseases that will probably kill most of us. A long RCT might measure the effect of a certain intervention over like five years but we need to think in terms of decades. No one is willing to fund those studies, and even if funding wasn't an issue the evidence would come too late for those of us alive today. So, we have to rely on weaker forms of evidence evaluated in a cost (or risk) versus benefit framework.

https://peterattiamd.com/outlive/

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#55

Post by haldujai » Thu, Jun 01, 2023, 11:00 PM UTC

rgbgraph wrote: post #53

importantbrian wrote: post #48

Earlier quoted context omitted.

What makes you conclude that statins are "bunkum"? I don't know anything about anti-depressants or surgical implants, but I have gone down the rabbit hole on statins and at least as far as I can tell they do what they are generally claimed to do, are safe, and so if you are at high risk for hear disease you should probably be taking them.

In bullet-points: - Absolute risk reduction in CVD-caused mortality is mild at best ( - Percentage of people that get side-effects is higher than the percentage of people that receive a benefit from statins; as well, the side-effects are rather serious in affecting QoL -- making them a poor choice as a long-term prophylactic - Generic lipid panels that the vast majority of people take are generally worthless for esti…

What patient population are you talking about? Statins have excellent evidence behind them.

> - Absolute risk reduction in CVD-caused mortality is mild at best (It depends what your baseline risk is and what time point you're looking at.

> - Percentage of people that get side-effects is higher than the percentage of people that receive a benefit from statins; as well, the side-effects are rather serious in affecting QoL -- making them a poor choice as a long-term prophylactic

This is just completely false, even from 2013 data[0] (which overestimates diabetes) but is better addressed in a subsequent review [1].

The side effects, if they do happen, are also self-limiting and stop with cessation or changing agents.

> - Generic lipid panels that the vast majority of people take are generally worthless for estimating lipid health ... and only loosely correlated with cardiovascular health

See reference [1] and [2].

[0]https://thennt.com/nnt/statins-for-heart-disease-prevention-...

[1]https://www.thelancet.com/article/S0140-6736(16)31357-5/full...

[2]https://www.onlinecjc.ca/article/S0828-282X(21)00165-3/fullt...

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#56

Post by nradov » Thu, Jun 01, 2023, 11:06 PM UTC

rgbgraph wrote: post #53

importantbrian wrote: post #48

Earlier quoted context omitted.

What makes you conclude that statins are "bunkum"? I don't know anything about anti-depressants or surgical implants, but I have gone down the rabbit hole on statins and at least as far as I can tell they do what they are generally claimed to do, are safe, and so if you are at high risk for hear disease you should probably be taking them.

In bullet-points: - Absolute risk reduction in CVD-caused mortality is mild at best ( - Percentage of people that get side-effects is higher than the percentage of people that receive a benefit from statins; as well, the side-effects are rather serious in affecting QoL -- making them a poor choice as a long-term prophylactic - Generic lipid panels that the vast majority of people take are generally worthless for esti…

There are multiple different statins. The latest research indicates that some are more effective than you indicate, with a lower rate of serious side effects.

https://peterattiamd.com/johnkastelein/

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#57

Post by nradov » Thu, Jun 01, 2023, 11:12 PM UTC

SkyPuncher wrote: post #38

jvanderbot wrote: post #33

Earlier quoted context omitted.

not op: but possibly ... The free exchange of information would make publicly funded data-driven discoveries more feasible. (?)

That's what standards like FIHR and HL7 do. While interchange is a problem, permissible use is a significantly higher bar.

FHIR is an HL7 standard. While conforming to FHIR makes interchange easier, it doesn't guarantee that the clinical data is accurate, complete, or properly coded. Researchers typically still have to put a huge amount of effort into data cleansing, especially if they need to merge data sets from multiple provider organizations.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#58

Post by rgbgraph » Thu, Jun 01, 2023, 11:13 PM UTC

nradov wrote: post #56

rgbgraph wrote: post #53

Earlier quoted context omitted.

In bullet-points: - Absolute risk reduction in CVD-caused mortality is mild at best ( - Percentage of people that get side-effects is higher than the percentage of people that receive a benefit from statins; as well, the side-effects are rather serious in affecting QoL -- making them a poor choice as a long-term prophylactic - Generic lipid panels that the vast majority of people take are generally worthless for esti…

There are multiple different statins. The latest research indicates that some are more effective than you indicate, with a lower rate of serious side effects. https://peterattiamd.com/johnkastelein/

I had an inkling I should have ended one of the points with that line of thought.

However, I haven't seen any research that shows more than minor absolute risk changes, regardless of statin -- they're the wrong drugs for the job.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#59

Post by haldujai » Thu, Jun 01, 2023, 11:14 PM UTC

LorenPechtel wrote: post #44

rgbgraph wrote: post #30

There was a great book about Evidence Based Medicine, from a woman out of Oxford, I read a long while ago. Can't for the life of me remember the name, but Oxford does have a center for "Evidence Based Medicine," and the whole idea has been slowly coming back into fashion. Instead, all I can recommend is a collection of essays -- loosely -- related to the subject: Where's the Evidence? , Silverman --- On another note,…

I do agree things should be studied but you have to be careful with it. Studies are big and expensive and things can be missed. Remember the big flap over hormone replacement therapy being shown harmful? Oops--all it really showed is what we knew all along, estrogen is risky for fat women.

> estrogen is risky for fat women

I think what you meant to say is unopposed estrogen is risky for all women.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#60

Post by pyuser583 » Thu, Jun 01, 2023, 11:15 PM UTC

spondylosaurus wrote: post #41

SkyPuncher wrote: post #35

Earlier quoted context omitted.

Being pedantic. Calling people out on HIPAA/HIPPA is like the warn out slight-of-hand trick you pull at a party and everyone pretends to laugh. I've never seen anyone who actually understands HIPAA get caught up on this. It's a common typo/misspelling.

You'd think it's a common typo, but I have literally only ever seen it spelled as "HIPPA" by people trying to use HIPAA as a punching bag for whatever happens to be their current pet issue. And those people almost always misspell it. The number of anti-vaxxers citing "HIPPA" as the reason why the local concert hall was trampling on their civil rights by asking to see proof of vaccination was... extremely high.

I worked in health insurance for years before I got it right.