My frustration with evidence-based medicine (EBM) and “clinical guidelines” was recently sparked by the visit of a new patient with persistent back and leg pain. The patient had been experiencing significant pain into his right leg for a couple of weeks.
Suffice it to say he was not responding to treatment, and after a few visits, I decided something was “fishy.” The symptoms, clinical signs and response to treatment just did not fit a tidy diagnosis.
An MRI could have been helpful – but his insurance company disagreed. In the opinion of the reviewer who denied my preauthorization request, the case did not fit the clinical “guidelines.”
Consequently, I referred him to a physiatrist friend, who managed to pull rank and get the MRI. The patient is doing good now, after having surgery for a huge lumbar synovial cyst. The guideline cookbook failed him, in my opinion.
The Problem With Today’s EBM
A treatment or diagnostic guideline cannot stand alone. It needs evidence; hence the name, “evidence-based medicine.” The components of EBM are said to be threefold: clinical experience, patient values and preferences, and the best available research evidence.1
But what if that evidence is statistically fraudulent, corrupt in its intent, or bought and paid for by nefarious forces or institutions? That is the subject of this article.
I read a few months ago about studies that have been cornerstones for the treatment of Alzheimer’s disease. These studies, done by one researcher, have been around for over 15 years and cited in other studies about 1,500 times. However, in 2021, a researcher from Vanderbilt proved these studies to be pure fiction.2
What is tragic about this realization is that treatment guidelines for Alzheimer’s, all these years, have been partially based on this falsified work.
No wonder a commentary was published in the British Medical Journal in March 2022, titled “The Illusion of Evidenced Based Medicine.”3 The teaser stated that EBM “has been corrupted by corporate interests, failed regulation, and the commercialization of academia.”
But the alarm has been going off for a long time. Superstar epidemiologist John Ioannidis has said for years that EBM has been “hijacked” by spurious research with little relevance to health outcomes.4
The Primary Players
Who are the players that contribute to these guidelines? Let’s start with Big Pharma, an easy target. Pharmaceutical companies spend tons of money on clinical studies, making sure they get the results that please them.
John Abramson, MD, writes in his book Sickening that before 1982, 80% of pharmaceutical research was done in academic medical institutions, but by 1996, only 26% was done there.5 The majority of drug research is now done by contract research firms that are either owned or controlled by pharmaceutical groups.
The second player in the guideline drama is academia. Other than Big Pharma, the National Institutes of Health (NIH) funds an enormous percentage of medical research in America. Grants from the NIH often go to the schools and scientists churning out the studies that the NIH value most. The temptation to cheat on research and meddle with statistics is enormous.
Evidence needs interpretation. That’s where the third piece of the EBM plot is introduced: peer review. It is too easy to point out that cash and power can corrupt reviewers. Abramson says there cannot be valid peer review without raw data and access to basic information; but reviewers are only supplied with manuscript summaries in most cases.6 Consequently, peer review often becomes the proverbial “rubber stamp of approval.”
How about the government? Guidelines can be used by government agencies to control medical practice and basically control populations (remember COVID?). Robert Kennedy Jr., in his well-documented book on Dr. Fauci, makes compelling arguments that Big Pharma essentially owns the FDA, the CDC, the AMA, and most of the government agencies that conjure up “the evidence” behind the use of drugs in clinical guidelines.7
Relevance to Our Profession
To sum it up, perverse incentives can lead scientists to produce fraudulent research that determines wrong-headed clinical practice and unreliable peer review. The critics of EBM point this out when they say medical practice is depending too much on the “reliable research” leg of the EBM triad (which may be unreliable), and not enough on the clinical expertise and patient preference legs.
The chiropractic profession has always honored clinical expertise and patient values. It’s who we are. But in regard to drug research, I think we may be fortunate we don’t prescribe drugs. I don’t want to go to bed at night worrying whether the Big Pharma medicine I could be giving patients is helping them or killing them.
But we practicing DCs do have to live by government dictates, as we learned from the COVID lockdowns. Let’s hope those dictates will be based on real evidence and not the misleading falsehoods we have witnessed in the past. For as the late scientist Stephen Hawking stated, “The greatest enemy of knowledge is not ignorance. It is the illusion of knowledge.”
References
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
| Digital Exclusive
A central challenge in creating our identity is that chiropractic is a method of care, not a technique or procedure. This is an important concept for us to promote. Our patients are treated with lifestyle modification, exercise, nutritional supplements, diet and a whole-body approach to accelerate the natural healing process. We are not simply CMT providers.
The results of a global survey released late last year (2023) unveiled some startling findings among medical and nursing students. The “Clinician of the Future: 2023 Education Edition” surveyed 2,212 students, of which 446 were in the United States, from 91 countries.
