Monday, January 16, 2006

Evidence based medicine--- old ideas recycled

It’s widely believed that evidence based medicine is a new idea. I’m not so sure. Although the general view is that the concept originated with Gordon Guyatt in 1992 I found something interesting in the almost century old Flexner Report (large pdf download).

The promoters of EBM say we need to replace dogma with evidence, tradition with science and physiologic assumptions with empiric observations. They tell us that old practice patterns need continual re-evaluation in the light of new evidence.

Great new ideas, right? Well, page 156 of the Flexner Report says-- “The modern point of view may be restated as follows: medicine is a discipline, in which the effort is made to use knowledge procured in various ways in order to effect certain practical ends. With abstract general propositions it has nothing to do. It harbors no preconceptions as to diseases or their cure. Instead of starting with a finished and supposedly adequate dogma or principle, it has progressively become less cocksure and more modest. It distrusts general propositions, a priori explanations, grandiose and comforting generalizations.” So this, Flexner’s view of the scientific basis of medicine, reads like a defense of EBM today.

A few sentences later Flexner issues a plea for evidence in medicine stating “It wants not dogma, but facts.” And, sounding again like an EBM apologist he says this concerning bias and conflict of interest in research: “The sectarian, on the other hand, begins with his mind made up. He possesses in advance a general formula, which the particular instance is going to illustrate, verify, reaffirm, even though he may not know just how. One may be sure that facts so read will make good what is expected of them; that only that will be seen which will sustain its expected function; that every aspect noted will be dutifully loyal to the revelation in whose favor the observer is predisposed: the human mind is so constituted.”
Another supposedly new tenet of EBM is the destruction of medical myths. But Flexner long ago recognized the hazard of medical myth: “Scientific medicine therefore brushes aside all historic dogma.” Finally, we all know how EMB decries reliance on experts. Flexner anticipated the problem, declaring “No man is asked in whose name he comes—whether that of Hahnemann, Rush, or of some more recent prophet. But all are required to undergo rigorous cross-examination.”
In these prescient words of Abraham Flexner we read the principles of EBM articulated some 95 years ago. (The full Flexner report is an interesting read, but long. A more easily accessible html page containing the section of the report referenced above can be found in this article from HomeoWatch).

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