Carl Heneghan recently wrote a blog for BMJ blogs entitled Evidence based medicine on trial focusing mostly on the problem with the evidence part of EBM. While I mostly concur with his list of the problems (distortion of the research agenda, very poor quality research, and lack of transparency for published evidence) I wonder who is at fault. “EBM” seems to get the blame as if there is an entity that is EBM and it controls all research. EBM is but a set of skills: question asking, searching, critical appraisal, and application to individual patients. It is nothing more. So why are people being so critical and place so much blame on a set of skills? There will be several sessions at EvidenceLive 2015 (one of which I will be speaking at in defense of EBM) on real vs rubbish EBM.
I want to focus on the distortion of the research agenda. Professor Heneghan rightly points out that the research agenda is driven by industry. Is that good or bad? I think its both but mostly good. The only other major funders of research are governmental agencies like the NIH. Profit drives innovation. It is very expensive to bring a drug to market. The government could not afford to bring the current drugs we have and need to market. One failed drug alone would deplete the coffers. Failure is the biggest driver of cost. Fewer than 1 in 10 drugs tested makes it to market. Would we tolerate that poor of a success rate at such a big cost by the government? No.
…adjusting that estimate for current failure rates results in an estimate of $4 billion in research dollars spent for every drug that is approved.
I agree that industry seems at times to make a drug then find a “disease” for it. I think the example Professor Heneghan gives is spot on. I don’t believe in adult ADHD but we have drugs for it. Do we need them? No and this video demonstrates why: Drug free treatment of ADHD. Who is really at fault are the doctors who prescribe the drugs that Professor Heneghan feels aren’t necessary. Not the companies for making them.
On a serious note…what about all the devices we use regularly like stents, defibrillators, etc? Would government have independently brought these to market? Likely not. We had balloon angioplasty (without stenting) that worked just fine albeit short term only. It would have been “good enough for government work” as the saying goes. What about advancements in imaging modalities? Again likely not. The old CT scanners worked just fine. Industry is largely responsible for innovation and improvement in all walks of life. Yes for a profit but profit is not a bad thing. Those who say otherwise please return your iPhones.
I completely agree with your statement”“EBM” seems to get the blame as if there is an entity that is EBM and it controls all research.” It is similar to people blaming science when scientists commits fraud/mistakes. EBM , like science, is a framework to make better decisions.