Epistemology-based Medicine:
A Superior Formula to “Evidence-based” Medicine.
Everywhere one goes in the field of medicine, and in science in general, we find the term “evidence-based”. They are even trying to use the term in politics and business. And mostly, if it isn’t an outright lie, it’s almost invariably a manipulation. For one thing it is a theory that has never been tested-a kind of medical catechism! For those who say it’s too difficult to test, that too is a lie.
Here is the simple protocol in my own field of psychiatry. Take one group, the experimental group and require that all the physicians justify each decision on the basis of a published article in the peer-reviewed literature-especially the prestigious ones like The American Journal of Psychiatry or The Annals of Psychiatry or the Journal of Clinical Psychiatry or the British Journal of Psychiatry (plenty to choose from lol).Then have the control group use just what they already know, their previous clinical experience and their clinical judgment. Then compare the results in a relatively simple diagnosis- like Major Depression where the rating scales are both valid and reliable.
But, just like the vaccine-mandate issue, which took more than 30 years to study! in the obvious format(anti-vaxxers vs. full CDC protocol vaxxers) no one wants to do this simple design study. They are afraid of the results! Personally, I would predict that the results would be more or less equivalent. But it is also quite possible that the docs using the evidence-based approach would do less well because of the rigidity implied by the model. That would destroy the entire church of “evidence-based science”! And no-one wants that-least of all the McGill University “expert” who completely lost it on me when I dared suggested this model. So much for objective science lol.
I first came in contact with this problem in the 1980’s when I was asked to teach a course on psychiatric research to the McGill Psychiatry residents. I came across a brilliant researcher who had reviewed the previous 10 years of psychiatric literature. What he did was study the career trajectory and theoretical biases of the lead authors (biological psychiatry, pharmacologically oriented, psychoanalytic and CBT mostly). Without reading the article he came to a conclusion about the authors’ preferred therapeutic approach. Not one of the published articles came to a conclusion contrary to what the bias of the lead author was expected to be! So much for objective science! And I am sure this is true in many other areas of medicine and science as well! Som what like asking a Democrat whether he would prefer Trump or Biden in the next election lol
In fact, there are many, many serious problems with this “evidence-based” approach. One of them was highlighted by a well-known researcher in ADHD who presented at the Canadian Psychiatric Conference ( I will protect her anonymity for now as we have to protect these brave, outspoken members of our medical community!). She stated clearly and courageously: ”Give me a break with evidence-based medicine! We will never have enough well-done studies to cover all the myriad decisions we need to make on a daily basis in medicine” Spot on! Bingo! In fact there are not enough resources in all the research funds available in all the world to do all those studies.
Other serious problems with “evidence-based” approaches include the following:
- Ideological beliefs of the researchers
- bias due to the funding of the research. This is probably the most universally recognized issue. Yet little is actually done about it.I know that at Psychiatric Conferences there is a ritualistic practice of citing all potential conflicts of interest. Then the presenter continues as if nothing he stated about his funding had any relevance! Pure and utter hypocrisy!
3) the constant statistical bugaboos of “selection bias” (look at the benzodiazepine studies in my field- almost all designed by anti-benzo activists) and “confounding variables” (no matter how much the researchers say they control for them!)
4) the difference between the study group( especially the exclusionary criteria )and the clinical groups where doctors have to treat every patient -not just selected ones. This was a big issue in psychiatry where research clinics had their set patient groups who were regularly used to test out new drugs. Psychiatrists were complaining that these groups didn’t correspond well to their own patient populations with multiple pathologies.
The list goes on and on..
In the end, these “gold-standard” studies are much less useful than most clinicians and researches believe. In my estimation, anecdotal evidence- (so disparaged by the fundamentalist scientific mind-set) from patients and other clinicians are far more useful. But that is heresy in the medical, scientific world lol! And if there is heresy, there must be religion hiding under the layers of “objective” science!
Before we proceed to some possible solutions to this dilemma, I would like to add in another data point-another anecdote, actually a series of anecdotes.! When I was working as a full-time psychiatrist, I was called upon to be an “expert witness” for a number of my clients-mostly about salary insurance issues . I noticed something very counter-intuitive as I watched the court proceedings unfold. The judges seemed to understand what was going on with the patients much more than the “expert witnesses” who were almost all doctors! How odd?! These people had legal training but they understood more clinical reality than the people with medical training?!
I thought long and hard about that one and in a way this article is, at least in part, the fruit of that reflection. How could this be?! Then I realized that the judges were taking account of many variables that the doctors were not. They were listening to the patients and their relatives (disparagingly looked at as “subjective” by the scientific community), they were taking account of the individual reports (“anecdotal evidence” as the scientific-minded would be inclined to reflexly think)and they were listening( how unempirical- for those bound up in Scientific Materialism).And yet, they were coming to the right conclusions more often than not. And why is that? And here is the punchline! Their Epistemology was much better and more comprehensive than the docs. They were not burying their heads in the sand of “randomized controlled trials published in prestigious medical journals.” What a relief!
By this point, you are probably catching the drift of where we are going in this discussion. We need a new Epistemology in medical science. When a patient comes out of the doctor’s office and says: ”He or she didn’t get at all what I was saying” we know we need a new approach. When the management of the Covid pandemic was so dysfunctional and chaotic, we know we need a new approach. And yes, there is a financial factor in all of it but in my estimation the ignorance factor is even greater than the greed! If you can imagine that.
Before I get into what that would look like I want to share an iconic episode that occurred during my psychiatric practice. At one point I was seeing a lot of Chronic Fatigue Syndrome patients. We lived at the time in a cottage with an in-law extension from where I did my practice. The children were not allowed on the clinical side but one day the cat escaped to the clinic and my youngest daughter ran over to catch it in the waiting room.
When I had finished my day’s work, I went over to the other side and she asked me: ”Daddy, who was that patient?” ”You know I am not allowed to tell you that, Sara , but why do you ask?” “She looked so sick”(she meant physically). I responded: “You are totally right about that(the patient in question had a cadaveric-green-gray colour to her skin tone)-but you know what is really amazing, Sara.? Two days ago, this lady went to see her G.P. and he looked at her test results and said: ”Madame, you are in perfect health. It’s all in your mind” As if that would help?!
So Empiricism has infected the entire enterprise of medicine so that contemporary doctors are no longer use their ears and eyes skilfully.. Instead they rely on blood tests and imaging! Which leads me back to the question of Epistemology .
What is this arcane Greek term anyway?! Epistemology is the Science of Knowledge. It refers to how you go about ascertaining what is true and what is real. Modernist Epistemology disproportionately favours Empiricism, “objective data” ,huge amounts of it preferably. And it loves statistical analysis and numbers. A recent article in the Lancet(a very prestigious medical journal) about Covid and its treatment had to be retracted because the data had been falsified. This is a rare event for peer-reviewed journals -until Covid at least! But the fraudulent researchers had tempted the editors with huge numbers (over 90,000 patients I believe). It was like candy to a baby. They were salivating at the numbers involved- like prospectors seeing a vein of gold in the rocks. Unfortunately, it turned out to be fool’s gold. Like a horny adolescent boy seeing a young lady with large breasts, the temptation was too strong lol!
Ok. Let’s get serious! What is the Epistemology I am recommending- for Medicine. It has to be much more comprehensive then it now is. The randomized placebo-controlled large scale studies could be part of the mix as well as non-randomized smaller studies( as were so useful in early Covid treatment) but both would have far less importance than they do now. Clinical experience is a far better indicator of what is going on. In my case, when a new psychopharmacological agent came out on the market after using it on 10 patients or less, I had a good idea of what it could do, what it couldn’t and what the problematic side effects were. The big numbers used in studies are used in order to generate statistical significance more than anything else. After all, how many times do you need to drink water to conclude that it relieves your thirst? Or how many friends do you need to question to feel confident that Puerto Vallarta is a good place to vacation in the winter lol?
On the other hand I once had a patient who was very preoccupied about which neighborhood in Montreal was the best place to live.So hev began his research. He visited them all, read all the data about the demographics, thought about it long and hard and eventually became very anxious and totally confused. Sounds like the management of the Covid pandemic to me. Too much information and too much data leads to confusion! The economists call this “the Law of Diminishing returns” The medical scientists haven’t caught on to that one yet. They still glory in large numbers!
My own spiritual epistemology has three doors: 1) hearing, 2) seeing and
The Zen Buddhists have come to much the same conclusions. Yes doctors have to start being “mensch”(to use a Yiddish/German term) and stop being robots and bureaucrats applying pat formulas and algorithms.They have to learn to listen. Not to be dismissive of what patients are saying-especially if it doesn’t fit their allopathic, Aristotelian models. They have to learn to see subtleties-like the pigmentation on the skin of the aforementioned patient. In fact, if you read accounts of 19th century physicians and psychiatrists you will see that they were much better observers than doctors nowadays. They didn’t have all those lab tests and imaging studies to rely on.
And last but not least doctors have to develop their feeling functions and their intuition. With those three in place we should have a much more effective medical practice. And then we can then study, if we are still in doubt, whether that works or not lol. My bets are that both Hippocrates and Galen would be on board .And we would all be the better for it!
Salaams, the prodigal doctor, Dr. Ibrahim Kreps
