“...science is an approach to truth seeking and sensemaking, while evidence-based medicine may operate under the basis that the truth or the underlying science has already been settled.”
That’s the crux of it right there for me. And ditto to Joomi’s comment on RCTs. And ditto to your comment on the need for critical thinking skills (there are many skills that need to be learned, but aren’t taught in schools at any level).
Recently I have seen this meme going around which is a spoof of scripture (which I would consider my life verse - it was even my Wi-Fi password) but it says “I can do all things through evidence based best practice which strengthens me” Peer Review 24:7. So yeah, that’s really placing quite a bit of faith in something that could easily fall apart, for example, C-19 vaccines prevent infection 99% of the time .... or perhaps it was actually nearly never. 🤦♀️
Yupp, I think there's an inherent assumption that RCT's and EBM will be enough to warrant the use of a therapeutic, but if it happens to fail, or it is later found to be toxic, would one really be aware of why that's the case? At the point that one reaches a clinical trial we would hope that there's enough evidence behind it to warrant the move towards human testing.
LOL. Prasad puts way too much faith in RCTs. He unironically calls them our "north star." Does he really not know the flaws with RCTs, or how often they end up showing contradictory results? No one should be listening to this man.
I think a big issue with RCTs is that it makes the assumption that you don't need to look at how things are being controlled.
I completely forgot that his recent remarks on a Long COVID RCT shows how little people look at the actual inclusion criteria for a diagnosis of Long COVID. The diagnosis is so broad that you'd never be able to delineate noise from signal, and so you look at the numbers and you get a "not statistically significant difference" result between groups. Prasad fails to rationalize that such a design is doomed to show no statistical significance from the start because no proper methods were done to differentiate control and experimental group.
Isn't it all really about financial incentives? Which is better business
A) to get someone well quickly, easily and cheaply, or
B) to get them dependent in you for ongoing treatment, especially to get them addicted to expensive drugs that they keep having to come back to you for
and
C) isn't it just good business to mandate that people inject themselves with poison that will cause them health problems which they will then come to for treatment for, especially if you've gotten the government to give you blanket immunity. And if unpleasant facts start coming out, at a certain point you can say "oh so sorry we didn't know"when in fact you knew all the time you were poisoning people for profit?
With respect to what research is funded and what trials are conducted, there's likely to be a ton of incentives done, and many doctors may receive some form of incentive for new drugs (the stickers plastered all over a doctor's office is intentional).
But the argument here is more towards education, and there's clear evidence that most doctors aren't able to read studies. Whether through improper education or lack of time, a doctor who can't discern what a drug does or why it would be considered better than other drugs may rely on knowledge brokers to provide them information. This may be some agency or a pharmaceutical rep, and so the information they receive is already inherently biased towards specific treatments.
I started Vinay's article and didn't finish. I'm married to a retired family practice physician who was "old" when she went to med school: 35. As such she'd led a life, been a nurses aid, RN, Nurse practitioner before going to med school. Her perspective was/is totally different than most doctors. Its not "evidence based" as that term is used, as that is just a way for pHarma to control the landscape. Instead I'd call it "patient based" medicine, and included herbs and supplements that were derided by her peers, yet over the years have shown to be a valid, even superior outcome based approach.
Medical education is captured by pHarma and is now run by the suits. It is not patient centered. It is pHarma centered. Until that changes people will find alternatives that work better, cheaper. Plus with the b.s. Of the last 3 1/2 years it's obvious that evidence based is just another politically correct narrative.
I had my suspicions about steroids so threw myself into a deep dive. They are great for some things but should really be a last resort, instead of first choice.
Yes, I used BPC, also Serapin, pitcher plant extract, plus acupuncture to me stop swelling and inflammation at bay. But it was platelet rich plasma injection combined with rRussian bioregulators that got me back dancing.
That appears to be the case for anyone receiving education with prior real-world experience to feel dissonant relative to their peers because they have gained a lot more perspective relative to students who move from one institution to the next until they graduate and go into the workforce. I won't deny that I was one of those people, and hence why my view of things has changed rather drastically over the past few years.
I think part of this also falls under the idea of arguing that RCTs and pharmaceutical products have already gone through some "rigorous, scientific" testing and is thus better than herbs which may have been used for centuries, but not validated through "proper" testing. I am always interested in what bioactive compounds in plants are beneficial, and there's an argument to be made that many people would lack the intuition to understand dosing and other aspects of herbs to get a full scope of what's going on. It's far easier to just take a pill with a fixed dose rather than understanding therapeutic dosage as a concept.
So all of these nuances are removed and streamlined, removing any want or need for critical thinking.
Right on. I think the movement from high school through med school without any real world perspective results in a big set of blinders. Reading comments on social media doc groups you can see the limited perspective and the brain washing, a lack of curiosity about what else is effective, denigration of alternatives, and a propensity to follow the bouncing ball to the MD and board certification.
Regarding herbs, I know what I know, and I read lots and know my limitations. I would state that a majority of the herbs available have limited side effects, and many synergistic potentials. Of course, it's good to know which ones do have contraindications, side effects to be aware of and which ones are low dose herbs, and toxic at higher doses, such as foxglove or poke.
"A pre-med student turned medical resident who neglects science would fall into the trap of prescribing Molnupiravir without being aware of its mutagenic properties." But they would certainly be experts in "Advancing Inclusive Excellence" and "Achieving Equity and Social Justice." (taken from the Harvard Medical School webpage)
Oh jeez, I was thinking of going down that tangent but decided not to. There's a lot to say there, as MCAT and medical schools have pivoted towards social justice activism. I was personally very critical of this because it doesn't seem like doctors are scientifically-inclined already, so now you're taking them and telling them to engage with equity and inclusivity rather than actual science. They're just trying to make activists who are serving as the face of the pharmaceutical industry. We can see this with how new medications may target minority communities under the guise of equity-that's actually the main reason used for the tiered system used for the vaccine rollouts, and apparently Biogen was questioned by Congress on whether Adulhelm was being pushed into minority communities.
Thanks for taking on this issue. Molnupiravir was a great example of "evidence based" limitations. (Some health systems were able to keep that drug off of the formulary. )
Evidence based medicine can't be evaluated without the framework of knowledge provided by biology, chemistry, and A&P. With a big picture view, your gut will tell you when you're looking at a garbage drug, or a garbage study, or quackery.
People with varying science and math backgrounds were able to give early warning about COVID policies and treatments.
To pick an antihypertensive, you don't want to google match the diagnosis with the drug. What if the patient has more than one problem? If you know the physiology and biochem, you can stack the antihypertensive based on what's causing the hypertension, what's up with patient's heart function, pharmacogenomic parameters, and which drugs they're currently taking.
(The "guidance" on how to choose antihypertensives changes quite often. )
The increasing proportion of medical studies that are later retracted is of huge concern.
Putting 'evidence based' medicine first means that an internist could be replaced by a search engine or an AI.
I think my biggest point with respect to Molnupiravir, and really should have been the case for all of these medical interventions, was to argue that Molnupiravir should have been seen through the lens of the precautionary principle. As soon as people became aware that its mechanism of action is through mutagenicity there should have been more scrutiny raised towards Merck to ensure that proper testing was done and questions were raised, and even then providing some additional hesitancy in its use. It wasn't until the committee hearing that some of the members were raising the question of if this drug could lead to mutations in SARS-COV2 that may escape. They even mentioned that family members who take Molnupiravir should isolate from other people in a household in case of such an event. So all of this should have raised some serious alarms, but a lot of people seemed to have overlooked that.
The Google thing is actually hilarious, because my friend worked in a hospital and she said she would see residents just looking up symptoms on WebMD in front of a patient... To be fair, nothing beats real-world experience, and a lot of medicine can be a guessing game until you hit on the pertinent questions and tests, but there's still something about hearing new doctors relying on websites that just seems pretty crazy.
I can tell you stories about those doctors. What might help with the guessing is if they actually know how to do a physical exam. So many of them don't really look at the patient anymore and they miss so much. There were always a few stand out physicians who guessed the best because they really looked at the patient. The rest of them followed protocols and order sets slavishly.
There have been published studies about the efficiency of literal Google diagnosis. It's entrenched.
A prediction that AI could replace physicians preceded the world wide availability of the internet.
Largest in my mind is that retroviruses rapidly mutate on their own, and have low percentage replication fidelity, because they don't have that error correction capability that organisms with DNA genome have. It was noticed sooo long ago that HIV mutates within the same patient. So my thinking was that molnupiravir was almost always going to be given too late to matter to the patient, and producing an actual superbug was a more of a potential risk. On the other hand, the observation that β-d-N4-hydroxycytidine produced mutations and toxicity in mammalian cells revved up my motor, and caused me to be glad that our institution wasn't going to deal out molnupiravir.
1) I have experience and education in a specialized field. But I am not a mechanic. I don’t care “how” my car works, I just want it fixed - but I expect the mechanic to know how it works and how to fix it. Post-COVID I trust the mechanic more than the physician.
2) Knowledge of the pre med sciences provides the foundation to understand disease processes. Instead of getting to the root cause of illnesses, medicine either treats SYMPTOMS with whatever medication is “approved”.
3) The goal of EBM originally was to incorporate the best available research, along with clinical experience and patient preference, into clinical practice. Somewhere along the way (ie big pharma) the process turned into a treatment algorithm (leading to corporate sponsored AI “providers.”)
With respect to any field, the issue is not that one wants it fixed, but if one does not know why they are having a problem or what process is being done to fix it, then you can be told anything without any ability to discern if it is actually something that's needed. A mechanic may fix your car, but would you be able to tell what is a necessary fix, or will additional, unnecessary work be done to bill you further? This is found in all fields. The biggest problem is that doctors are dealing with a person's health, and the consequences could be far more dire within that circumstance.
But I think all your points are warranted, and certainly with #3. It's likely that the intention of EBM started out well-meaning, but got corrupted.
“...science is an approach to truth seeking and sensemaking, while evidence-based medicine may operate under the basis that the truth or the underlying science has already been settled.”
That’s the crux of it right there for me. And ditto to Joomi’s comment on RCTs. And ditto to your comment on the need for critical thinking skills (there are many skills that need to be learned, but aren’t taught in schools at any level).
Recently I have seen this meme going around which is a spoof of scripture (which I would consider my life verse - it was even my Wi-Fi password) but it says “I can do all things through evidence based best practice which strengthens me” Peer Review 24:7. So yeah, that’s really placing quite a bit of faith in something that could easily fall apart, for example, C-19 vaccines prevent infection 99% of the time .... or perhaps it was actually nearly never. 🤦♀️
Yupp, I think there's an inherent assumption that RCT's and EBM will be enough to warrant the use of a therapeutic, but if it happens to fail, or it is later found to be toxic, would one really be aware of why that's the case? At the point that one reaches a clinical trial we would hope that there's enough evidence behind it to warrant the move towards human testing.
LOL. Prasad puts way too much faith in RCTs. He unironically calls them our "north star." Does he really not know the flaws with RCTs, or how often they end up showing contradictory results? No one should be listening to this man.
I think a big issue with RCTs is that it makes the assumption that you don't need to look at how things are being controlled.
I completely forgot that his recent remarks on a Long COVID RCT shows how little people look at the actual inclusion criteria for a diagnosis of Long COVID. The diagnosis is so broad that you'd never be able to delineate noise from signal, and so you look at the numbers and you get a "not statistically significant difference" result between groups. Prasad fails to rationalize that such a design is doomed to show no statistical significance from the start because no proper methods were done to differentiate control and experimental group.
Isn't it all really about financial incentives? Which is better business
A) to get someone well quickly, easily and cheaply, or
B) to get them dependent in you for ongoing treatment, especially to get them addicted to expensive drugs that they keep having to come back to you for
and
C) isn't it just good business to mandate that people inject themselves with poison that will cause them health problems which they will then come to for treatment for, especially if you've gotten the government to give you blanket immunity. And if unpleasant facts start coming out, at a certain point you can say "oh so sorry we didn't know"when in fact you knew all the time you were poisoning people for profit?
With respect to what research is funded and what trials are conducted, there's likely to be a ton of incentives done, and many doctors may receive some form of incentive for new drugs (the stickers plastered all over a doctor's office is intentional).
But the argument here is more towards education, and there's clear evidence that most doctors aren't able to read studies. Whether through improper education or lack of time, a doctor who can't discern what a drug does or why it would be considered better than other drugs may rely on knowledge brokers to provide them information. This may be some agency or a pharmaceutical rep, and so the information they receive is already inherently biased towards specific treatments.
I started Vinay's article and didn't finish. I'm married to a retired family practice physician who was "old" when she went to med school: 35. As such she'd led a life, been a nurses aid, RN, Nurse practitioner before going to med school. Her perspective was/is totally different than most doctors. Its not "evidence based" as that term is used, as that is just a way for pHarma to control the landscape. Instead I'd call it "patient based" medicine, and included herbs and supplements that were derided by her peers, yet over the years have shown to be a valid, even superior outcome based approach.
Medical education is captured by pHarma and is now run by the suits. It is not patient centered. It is pHarma centered. Until that changes people will find alternatives that work better, cheaper. Plus with the b.s. Of the last 3 1/2 years it's obvious that evidence based is just another politically correct narrative.
Just sayin
I had my suspicions about steroids so threw myself into a deep dive. They are great for some things but should really be a last resort, instead of first choice.
https://doorlesscarp953.substack.com/p/corticosteroids-mechanisms-of-action
Wow! Deep dive indeed. We've been using peptides in liu of steroid injections with good results in my knees.
Thanks! A quick search shows studies going back decades. I found this one:
Intra-Articular Injection of BPC 157 for Multiple Types of Knee Pain
Edwin Lee et al. Altern Ther Health Med. 2021 Jul
https://pubmed.ncbi.nlm.nih.gov/34324435/
Yes, I used BPC, also Serapin, pitcher plant extract, plus acupuncture to me stop swelling and inflammation at bay. But it was platelet rich plasma injection combined with rRussian bioregulators that got me back dancing.
That appears to be the case for anyone receiving education with prior real-world experience to feel dissonant relative to their peers because they have gained a lot more perspective relative to students who move from one institution to the next until they graduate and go into the workforce. I won't deny that I was one of those people, and hence why my view of things has changed rather drastically over the past few years.
I think part of this also falls under the idea of arguing that RCTs and pharmaceutical products have already gone through some "rigorous, scientific" testing and is thus better than herbs which may have been used for centuries, but not validated through "proper" testing. I am always interested in what bioactive compounds in plants are beneficial, and there's an argument to be made that many people would lack the intuition to understand dosing and other aspects of herbs to get a full scope of what's going on. It's far easier to just take a pill with a fixed dose rather than understanding therapeutic dosage as a concept.
So all of these nuances are removed and streamlined, removing any want or need for critical thinking.
Right on. I think the movement from high school through med school without any real world perspective results in a big set of blinders. Reading comments on social media doc groups you can see the limited perspective and the brain washing, a lack of curiosity about what else is effective, denigration of alternatives, and a propensity to follow the bouncing ball to the MD and board certification.
Regarding herbs, I know what I know, and I read lots and know my limitations. I would state that a majority of the herbs available have limited side effects, and many synergistic potentials. Of course, it's good to know which ones do have contraindications, side effects to be aware of and which ones are low dose herbs, and toxic at higher doses, such as foxglove or poke.
"A pre-med student turned medical resident who neglects science would fall into the trap of prescribing Molnupiravir without being aware of its mutagenic properties." But they would certainly be experts in "Advancing Inclusive Excellence" and "Achieving Equity and Social Justice." (taken from the Harvard Medical School webpage)
Oh jeez, I was thinking of going down that tangent but decided not to. There's a lot to say there, as MCAT and medical schools have pivoted towards social justice activism. I was personally very critical of this because it doesn't seem like doctors are scientifically-inclined already, so now you're taking them and telling them to engage with equity and inclusivity rather than actual science. They're just trying to make activists who are serving as the face of the pharmaceutical industry. We can see this with how new medications may target minority communities under the guise of equity-that's actually the main reason used for the tiered system used for the vaccine rollouts, and apparently Biogen was questioned by Congress on whether Adulhelm was being pushed into minority communities.
Thanks for taking on this issue. Molnupiravir was a great example of "evidence based" limitations. (Some health systems were able to keep that drug off of the formulary. )
Evidence based medicine can't be evaluated without the framework of knowledge provided by biology, chemistry, and A&P. With a big picture view, your gut will tell you when you're looking at a garbage drug, or a garbage study, or quackery.
People with varying science and math backgrounds were able to give early warning about COVID policies and treatments.
To pick an antihypertensive, you don't want to google match the diagnosis with the drug. What if the patient has more than one problem? If you know the physiology and biochem, you can stack the antihypertensive based on what's causing the hypertension, what's up with patient's heart function, pharmacogenomic parameters, and which drugs they're currently taking.
(The "guidance" on how to choose antihypertensives changes quite often. )
The increasing proportion of medical studies that are later retracted is of huge concern.
Putting 'evidence based' medicine first means that an internist could be replaced by a search engine or an AI.
Then...... Garbage in, Garbage out.
I think my biggest point with respect to Molnupiravir, and really should have been the case for all of these medical interventions, was to argue that Molnupiravir should have been seen through the lens of the precautionary principle. As soon as people became aware that its mechanism of action is through mutagenicity there should have been more scrutiny raised towards Merck to ensure that proper testing was done and questions were raised, and even then providing some additional hesitancy in its use. It wasn't until the committee hearing that some of the members were raising the question of if this drug could lead to mutations in SARS-COV2 that may escape. They even mentioned that family members who take Molnupiravir should isolate from other people in a household in case of such an event. So all of this should have raised some serious alarms, but a lot of people seemed to have overlooked that.
The Google thing is actually hilarious, because my friend worked in a hospital and she said she would see residents just looking up symptoms on WebMD in front of a patient... To be fair, nothing beats real-world experience, and a lot of medicine can be a guessing game until you hit on the pertinent questions and tests, but there's still something about hearing new doctors relying on websites that just seems pretty crazy.
I can tell you stories about those doctors. What might help with the guessing is if they actually know how to do a physical exam. So many of them don't really look at the patient anymore and they miss so much. There were always a few stand out physicians who guessed the best because they really looked at the patient. The rest of them followed protocols and order sets slavishly.
There have been published studies about the efficiency of literal Google diagnosis. It's entrenched.
A prediction that AI could replace physicians preceded the world wide availability of the internet.
Largest in my mind is that retroviruses rapidly mutate on their own, and have low percentage replication fidelity, because they don't have that error correction capability that organisms with DNA genome have. It was noticed sooo long ago that HIV mutates within the same patient. So my thinking was that molnupiravir was almost always going to be given too late to matter to the patient, and producing an actual superbug was a more of a potential risk. On the other hand, the observation that β-d-N4-hydroxycytidine produced mutations and toxicity in mammalian cells revved up my motor, and caused me to be glad that our institution wasn't going to deal out molnupiravir.
Random comment:
1) I have experience and education in a specialized field. But I am not a mechanic. I don’t care “how” my car works, I just want it fixed - but I expect the mechanic to know how it works and how to fix it. Post-COVID I trust the mechanic more than the physician.
2) Knowledge of the pre med sciences provides the foundation to understand disease processes. Instead of getting to the root cause of illnesses, medicine either treats SYMPTOMS with whatever medication is “approved”.
3) The goal of EBM originally was to incorporate the best available research, along with clinical experience and patient preference, into clinical practice. Somewhere along the way (ie big pharma) the process turned into a treatment algorithm (leading to corporate sponsored AI “providers.”)
4) Buyer beware
With respect to any field, the issue is not that one wants it fixed, but if one does not know why they are having a problem or what process is being done to fix it, then you can be told anything without any ability to discern if it is actually something that's needed. A mechanic may fix your car, but would you be able to tell what is a necessary fix, or will additional, unnecessary work be done to bill you further? This is found in all fields. The biggest problem is that doctors are dealing with a person's health, and the consequences could be far more dire within that circumstance.
But I think all your points are warranted, and certainly with #3. It's likely that the intention of EBM started out well-meaning, but got corrupted.
And of course out turns out that Vinay's "article" was a chat AI piece. So I've unsubscribed.