Tarnished Gold Chapter 3: Prove It

This chapter dealt with the issues of what constitutes evidence. Instead of focusing on their views I will focus on my views of evidence.


A common criticism of EBM is that it very strict in what it considers¬† acceptable evidence and it doesn’t consider clinical experience and pathophysiological rationale as important. Early EBM did focus too much on the RCT and Cochrane systematic reviews but this has changed. The current EBM paradigm focuses on multifactorial “evidence” including the patient’s clinical state and circumstances, clinical experience, and the best available evidence. Sometimes this will be a systematic review but often it will just be patient experience (what worked or didn’t work for them in the past) or pathophysiology. The early EBM paradigm cautioned us that we can be misled by our unsystematic observations and the pathophysiological rationale. For the latter, it’s because our understanding of pathophysiology changes and diseases are complex and multifactorial and interventions we study tend to be unifactorial. Nonetheless, clinical experience is evidence and is very important and no EBMer will say otherwise. Understanding pathophysiology is important and no EBMer will say otherwise. The key is to understand the limitations of any evidence source.

Evidence supports a belief and doesn’t have to be true. In clinical medicine we can never know the truth. We can only try to estimate the truth with a study because we can’t study every person with a given disease. We have to infer a lot. We generalize from a sample in a study to a whole population and back down to an individual patient. The authors of Tarnished Gold have a real problem with this paradigm but it’s what we do in clinical medicine. Bench research works differently. Rats can all be genetically and phenotypically the same. Bacteria can all be clones of each other. Bench scientists can study a whole population of something and declare an effect. We can’t do this in clinical medicine because we are all so heterogeneous and have free will.

EBM no longer worships only the RCT and the Cochrane review. Patient inputs are viewed as very important and slowly becoming equally important. Qualitative studies are gaining importance. Clinical experience will always be prominent in deciding what should be done from what could be done.

Tarnished Gold Chapter 2: Populations are not people

Populations are not people

First off the authors state that decisions sciences do not relate to EBM. They feel decisions are personal and statistical information is not important. They give the example of organ transplantation. Unfortunately, they skip an important step in their argument. Namely, that to know an organ transplant will be of benefit is based upon studies proving that they prolong life and these are based on statistical information.

They argue that EBM is based on a statistical blunder: the ecological fallacy.¬† There is some merit to this argument. The average finding applies to the average patient. What if your patient isn’t average. There are a couple of options. First, you could calculate your patient’s estimate of benefit (or risk) using the results from the study like I demonstrate in this video.¬† Almost every study report will include a confidence interval around the point estimate of benefit (or harm). The point estimate is the best guess about the findings of the study but there is uncertainty and the confidence interval helps quantify that uncertainty. You could use the upper and lower bounds of the confidence interval and decide if it includes a clinically important benefit. Finally, you could look for a subgroup analysis (yes I recognize the limitations of this) of a group of patients similar to yours. Despite all this, science is based on inference. We can never measure the effect of an intervention in all people. We often use inductive and deductive reasoning in science.

The authors spent several pages discussing pattern recognition in medicine and that EBM doesn’t help this. This is both true and false. It is true in that we are taught how certain things look and there will never be a study related to that. We have numerous studies though of how good elements of the history and PE are for diagnosing disease. Many of these are pattern recognition. We learn that peripheral edema, orthopnea, PND, and DOE are most likely congestive heart failure. That is pattern recognition but there is also a study that examines how good each of these components is to increasing or decreasing the probability of CHF. Thus, pattern recognition is informed by EBM.

There are more claims to be refuted in this chapter but these are the main ones worth refuting.