Bernadine Healy weighs in on EBM (September 11, 2006)

An earlier weblog entry,

discussed a harsh criticism of Evidence Based Medicine that was published in

A brief commentary by Bernadine Healy published in U.S. News and World Report,

cites this research, and while not quite agreeing with the harsh language (Holmes et al repeatedly compare proponents of EBM with fascists), does argue that

By anointing only a small sliver of research as best evidence and discarding or devaluing physician judgment and more than 90 percent of the medical literature, patients are forced into a one-size-fits-all straitjacket.

Dr. Healy cites two examples of when EBM has (in her opinion) gone astray: mammograms and PSA testing. Dr. Healy sets up a false dichotomy when she states

Remember the mammogram wars over whether women should get them during their 40s? The protagonists were the EBM-ers who said no and the radiologists and oncologists who said yes.

Some proponents of EBM supported the use of mammograms for women in their 40s and some radiologists and oncologists discouraged their use.

Dr. Healy's comments about PSA testing are also interesting.

EBM also questions the prostate-specific antigen test, or PSA, for prostate cancer. The evidence-based method concludes that the test brings more harm than benefit, as it leads to unneeded biopsies and surgeries on often slow-growing cancers.

She then goes on to cite an interesting case study of a doctor who used EBM to justify not testing the PSA levels in a particular patient.

This does not help that young primary-care doctor who published a mournful essay in the Journal of the American Medical Association in 2004. He did not get a PSA on his 53-year-old patient, based on his dutiful practice of evidence-based medicine. When found to have advanced prostate cancer, the patient sued and won. The jury put its faith in the medical experts who testified that PSAs are the best way to pick up tumors when they are most treatable.

The JAMA article is

and it is worth noting that the author of this article draws the exact opposite conclusion of Dr. Healy. Dr. Merenstein describes the patient encounter where he outlined  the risks and benefits of PSA testing.

When the trial started on June 23, 2003, I was nervous but confident. I realized that the patient was going to say we had never discussed prostate cancer screening but since I always do and had documented it, I didn't think this would be a very strong plaintiff argument. What I didn't anticipate was that the plaintiff's attorney was going to argue that I should have never discussed the risks and benefits and should have just ordered the PSA. But he did. In fact, a major part of his argument was that there is little risk involved in performing a PSA and that the standard of care is to order the test. Although we had the recommendations from every nationally recognized group supporting my approach and the literature is clear that screening for prostate cancer is controversial, the plaintiff's attorney argued otherwise.

Dr. Merenstein is a firm advocate of EBM.

As a family physician I have reveled in keeping up-to-date and providing my patients with the best possible medicine.

The opposing attorney provided a different characterization of EBM

During closing arguments the plaintiff's lawyer put evidence-based medicine on trial. He threw EBM around like a dirty word and named the residency and me as believers in EBM, and our experts as the founders of EBM. He defined EBM as a cost-saving method and stated his belief that the few lives saved were not worth the money. He urged the jury to return a verdict to teach residencies not to send any more residents on the street believing in EBM.

that mirrors the arguments by Holmes et al. Dr. Healy also seems to support this perspective by identifying opponents of PSA testing and early mammograms as seemingly only concerned about money. In truth, both examples offer situations where there is cost in human suffering associated with the false positives that these tests offer. The next step after a positive PSA test, for example, is a biopsy that may sometimes produce incontinence and impotence, two "I" words that I greatly dread. Do the lives saved by PSA testing balance out the lives harmed by PSA testing? It's hard to say, but it is worth noting that Dr. Merenstein discussed the test with his patient, and the lawyer in the case advocated that the PSA test should be conducted routinely without offering the patient a choice. So who's the fascist here?

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