Is Evidence Based Medicine at a Dead End?
Evidence-Based Medicine (EBM) as practiced today (and not as originally conceived by Sackett), emphasizes fact-based medicine. The best facts for EBM are those which are gathered through double-blind (where neither the physician/veterinarian nor the patient/pet owner know what they are getting) placebo-controlled (where patients/pets get either the actual treatment or an inactive placebo) studies, and which are reviewed by looking at all such studies, throwing out inadequate studies, and comparing all the rest. Large numbers of responses are analyzed, so this is valid for populations as a whole. In veterinary medicine this is called herd medicine, and decisions are made that will best protect the whole herd.
When the treatment is a pill or injection, the study is fairly easy to create: find patients who have the same stage of a disease, create fake (placebo) pills or injectible placebo solutions that look like the real ones but which have no effect on the body, assign patients at random to receive real or fake treatments, and see if the real treatment works better than the fake one.
By insisting that the only valid studies are double-blind placebo studies, EBM automatically rules any treatment that involves physical manipulation of the body as having sub-standard research. Acupuncture, for example, has no satisfactory placebo. There are a number of studies which show that, in humans, puncturing the skin anywhere with acupuncture needles produces an effect, even if it is not in an acupuncture point. Some studies have used needles which look like acupuncture needles and cause a sensation but do not puncture the skin. Even so, the physician/veterinarian knows which type they are using, and if the sham needles and real needles are used on the same point, the sham needles and their needle guides are performing acupressure.
There are similar problems when studying chiropractic, massage therapy, and trigger point therapy. Whoever is doing the treatment knows whether the patient is getting a “real” treatment or not. So there is no blinding of the physician/veterinarian. If the human patient has had any of these treatments themselves previously, they also know immediately whether or not they have received a treatment. With a pet, if the owner allows the pet to be taken away for treatment, the owner will not know (although they may be able to tell from the behavior of the pet after they have been treated). Therefore there can’t be a double blind study for manipulative therapies so, according to EBM standards, any research on these areas will be substandard.
Conventional science seeks to understand treatments at the molecular level: if I give drug A to decrease high blood pressure, how does it actually achieve that, step by step all the way down to individual molecules signaling cells to do things? Single drugs are developed for single purposes. Diseases are given single names, and are described as a specific list of symptoms. This can work well for diseases caused by single organisms or abnormal levels of single hormones and which stick to specific patterns. Drugs that kill the organism or replace hormones that are present in subnormal amounts, can cure or control these diseases fairly well. This type of disease process can be studied by the gold standard double blind study. But it does not address the needs of patients with complex symptoms that are not easily standardized, or those with a untreatable terminal or chronic disease looking for better quality of life, or an improvement in any symptoms that do not match the standard list of symptoms.
Complementary and Alternative Medicine (CAM) looks at patterns of disease in an individual, and patterns of their responses to CAM treatments. Herbs are often given in combinations, less often as single herbs. Whole herbs or herbal extracts (including teas) are given rather than a single component of the herb. As a result, diseases are not defined in a Western sense, and, when trying to find and study the one single component of a treatment that works for a disease or pattern, results are less than satisfactory. In Western medicine, diet is often ignored. In CAM, diet is a big part of the treatment and without the proper diet, the rest ot the treatment is more likely to fail. Because of the multiplicity of symptoms in a disease pattern, one cannot assign one treatment to one single effect. Because of the complexity of an herbal formula and the myriad of effects in the body, one cannot identify one single effect as being the only way it works.
Double blind studies ignore the individual. They usually ignore quality of life. CAM studies should be judged by whether patients with similar disease patterns improve from similar treatments, rather than trying to isolate single actions of single treatments on single diseases. More studies of drug-herb interactions, especially as they may benefit chronic disease or decrease side effects would also be of benefit. This way the strong points of both CAM and Western medicine could be studied to the benefit of improving treatment of chronic disease.
References
Borgerson K., Evidence-based alternative medicine? Perspect Biol Med. 2005.
Harlan WR Jr., New opportunities and proven approaches in complementary and alternative medicine research at the National Institutes of Health. J Altern Complement Med. 2001.
Harlan WR Jr., Research on complementary and alternative medicine using randomized controlled trials. J Altern Complement Med. 2001.
Tonelli MR, et al. Why alternative medicine cannot be evidence-based. Acad Med. 2001.
Vanherweghem JL. [Evidence-based medicine and art of healing: the dead end of incommensurate paradigms]. Bull Mem Acad R Med Belg. 2005.
Vanherweghem JL. [Alternative medicines and “Evidence-Based Medicine” a possible reconciliation?]. Rev Med Brux. 2015.
Yan XF, et al. Evidence-based practice method of integrative Chinese and Western medicine based on literature retrieval through PICO question and complementary and alternative medicine topics. Chin J Integr Med. 2010.
