Gift Horse or Trojan Horse? The EBM debate continues

 A colleague just brought the June 2006 issue of Social Science and Medicine to my attention. This issue contains a special section on evidence-based medicine. Here are the PubMed records for the entire issue, but I am including the nine EBM abstracts below. A subscription is required for full text.

Lambert H, Gordon EJ, Bogdan-Lovis EA. Introduction: Gift horse or Trojan horse? Social science perspectives on evidence-based health care. Social Science & Medicine 2006; 62(11):2613-2620.

Excerpt: In this introduction, we provide some background to the contents of this Special Issue by outlining briefly the key components and attendant assumptions of evidence-based approaches to health care, and summarise the main advantages and limitations of this approach according to its champions and detractors. We then offer a synopsis of each paper before reflecting on the intersecting themes, topics and implications for social science understandings of EBM that emerge from the collection as a whole. The Special Issue originated in two conference panels convened independently by the present authors. In 2003, Elizabeth (Libby) Bogdan-Lovis and Elisa Gordon, together with Kate Bent, convened a panel on, Gift horse or Trojan horse?: Evidence-based Practice Transforming Medicine at the American Anthropological Association annual meetings, while Helen Lambert organised a panel entitled, Anthropology and Medical Science: Notions of Evidence for the 2003 UK Association of Social Anthropologists’ Decennial conference. This Special Issue includes a selection of the papers originally presented on those occasions.

Goldenberg MJ. On evidence and evidence-based medicine: Lessons from the philosophy of science. Social Science & Medicine 2006; 62(11):2621-2632.

Abstract: The evidence-based medicine (EBM) movement is touted as a new paradigm in medical education and practice, a description that carries with it an enthusiasm for science that has not been seen since logical positivism flourished (circa 1920-1950). At the same time, the term “evidence-based medicine” has a ring of obviousness to it, as few physicians, one suspects, would claim that they do not attempt to base their clinical decision-making on available evidence. However, the apparent obviousness of EBM can and should be challenged on the grounds of how `evidence’ has been problematised in the philosophy of science. EBM enthusiasm, it follows, ought to be tempered.The post-positivist, feminist, and phenomenological philosophies of science that are examined in this paper contest the seemingly unproblematic nature of evidence that underlies EBM by emphasizing different features of the social nature of science. The appeal to the authority of evidence that characterizes evidence-based practices does not increase objectivity but rather obscures the subjective elements that inescapably enter all forms of human inquiry. The seeming common sense of EBM only occurs because of its assumed removal from the social context of medical practice. In the current age where the institutional power of medicine is suspect, a model that represents biomedicine as politically disinterested or merely scientific should give pause.  

Lambert H. Accounting for EBM: Notions of evidence in medicine. Social Science & Medicine 2006; 62(11):2633-2645.

Abstract: This paper takes as a focus of anthropological enquiry the set of techniques and practices for the appraisal and clinical application of research evidence that has become known as evidence-based medicine (EBM) (or, more recently, evidence-based health care). It first delineates and classifies the criticisms of EBM emerging from within the health professions. It then charts the evolution of EBM in responding to these criticisms and uncovers its character as a pedagogical innovation aimed at transforming clinical practice. It identifies EBM as an indeterminate and malleable range of techniques and practices characterised not by particular kinds of methodological rigour, but by the pursuit of a new approach to medical knowledge and authority. It situates this characterisation within a contemporaneous political and economic climate of declining trust and growing accountability. This analysis provides a basis from which to consider the notions of evidence implicit in EBM itself and also in the qualitative social sciences, including anthropology, which not only critique but also contribute to these notions themselves. Finally, the paper considers possible future trajectories for EBM with regard to the incorporation of cultural and structural dimensions of health and the inclusion of qualitative material in the evidence base. 

Barry CA. The role of evidence in alternative medicine: Contrasting biomedical and anthropological approaches. Social Science & Medicine 2006; 62(11):2646-2657.  Full Text

Abstract: The growth of alternative medicine and its insurgence into the realms of the biomedical system raises a number of questions about the nature of evidence. Calls for `gold standard’ randomised controlled trial evidence, by both biomedical and political establishments, to legitimise the integration of alternative medicine into healthcare systems, can be interpreted as deeply political. In this paper, the supposed objectivity of scientific, biomedical forms of evidence is questioned through an illumination of the multiple rhetorics embedded in the evidence-based medicine phenomenon, both within biomedicine itself and in calls for its use to evaluate alternative therapeutic systems. Anthropological notions of evidence are constructed very differently from those of biomedical science, and offer a closer resonance with the philosophy of alternative medicine. Examples are given of the kinds of evidence produced by anthropologists researching alternative medicine. Ethnographic evidence of `what works’ in alternative medicine includes concepts such as transcendent, transformational experiences; changing lived-body experience; and the gaining of meaning. It is proposed that the promotion of differently constructed modes of evidence can be used to legitimise alternative medicine by widening the definition of what works in therapy, and offering a critique of what people feel is lacking from much of orthodox medical care.  

Naraindas H. Of spineless babies and folic acid: Evidence and efficacy in biomedicine and ayurvedic medicine. Social Science & Medicine 2006; 62(11):2658-2669.

Abstract: The basic premise of the paper is that Western medicine’s co-opting of specific technologies and materials from other (indigenous) medical traditions, stripped of the original theories underlying their use, has problematic consequences for the practitioners and patients of both source and recipient traditions. The paper begins by illustrating the historical continuity of this process by way of an example from India‘s colonial era. The fact that specific practices or materials are regarded as biomedically useful because they `work’ (are efficacious) does not mean that the `traditional’ theories underlying them are seen as correct. The knowledge contained in these traditions is not counted as legitimate, as the emphasis in biomedicine (the legitimate canon) on an identifiable concrete location in the body for the source of health problems creates difficulties–both for patients when their problems are not provided with a cause that matches their subjective awareness, and for the practitioners of other traditions whose patients have been exposed to biomedicine. The paper goes on to demonstrate, using case examples from extended ethnographic fieldwork in southern India, how this is played out in a setting in which an educated Indian patient population accepts this form of knowledge as legitimate but espouses ayurvedic therapy. Notions of `evidence’ are shown to be central to the interplay between biomedical and other medical traditions, since objective tests and measures in biomedicine are accepted as the only legitimate `evidence’ of cure, but these do not necessarily accord either with the premises of these other traditions or with patients’ subjective perceptions of well-being. Returning to an acceptance and practice of other traditions, consequently, requires nothing less than a fundamental cognitive shift in the grounds for what constitutes `evidence.’ 

Landsman GH. What evidence, whose evidence?: Physical therapy in New York State‘s clinical practice guideline and in the lives of mothers of disabled children. Social Science & Medicine 2006; 62(11):2670-2680.

Abstract: To provide recommendations based on the best scientific evidence available about “best practices,” the New York State Department of Health Early Intervention Program sponsored the development of an evidence-based clinical practice guideline for assessment and intervention for young children with motor disabilities. The author served on the multidisciplinary consensus panel convened to develop the guideline, holding a position as a parent of a child with motor disabilities, and in addition utilizing data from her qualitative anthropological research on mothers of young children newly diagnosed with disabilities. This article describes the state panel’s process for developing the guideline, focusing on recommendations about physical therapy interventions for cerebral palsy. Although evidence-based practice privileges randomized clinical trials, few studies of physical therapy techniques for young children with motor disabilities meet such criteria for evidence. The panel’s recommendations, in the absence of such scientific evidence, are analyzed in comparison with competing theories of motor development in physical therapy research and practice, and with interpretations of physical therapy held by mothers of young children with disabilities who were interviewed in the study. The article explores questions of what constitutes evidence in three arenas: (1) clinical practice guidelines, (2) physical therapy research, and (3) the lives of families of young children with motor disabilities. It has broader implications for understanding how information, variously derived, is transformed into evidence. While to some extent authority and power affect the range of knowledge that can be transformed into evidence, the more significant constraints may be the rules of evidence we value and the particular paradigm of our science.  

Bogdan-Lovis EA, Sousa A. The contextual influence of professional culture: Certified nurse-midwives’ knowledge of and reliance on evidence-based practice. Social Science & Medicine 2006; 62(11):2681-2693.

Abstract: This paper reports research undertaken to assess US certified nurse-midwives’ (CNMs) knowledge of, access to, and use of evidence-based medicine (EBM). Findings are presented in the context of interprofessional, institutional, and popular culture. The descriptive study follows concepts of diffusion of innovation, evidence-based patient choice, and authoritative knowledge to analyse incentives and barriers to the implementation of evidence-based midwifery care.Structured interviews were conducted with practicing CNMs in an urban practice site and a regional teaching centre. The analysis of responses explored congruence between practitioner knowledge, professed practice, and published professional as well as hospital-based internal practice guidelines, for two specific interventions for which there is ample systematic review, epidural and episiotomy. The CNMs demonstrated enthusiasm for their own individual understanding of EBM, but responses to specific questions about EBM-supported practice indicate that many had an incomplete understanding of the concept. Furthermore, in those cases where CNMs demonstrated accurate knowledge of EBM, practice protocols followed subspecialty dictates, thereby preventing their knowledge from translating into adherence to EBM-guided clinical practice guidelines. Finally, patient expectations for technological intervention appeared to influence CNMs’ care decisions, even when those expectations lacked sound supporting evidence.If, as conceived by its originators and champions, EBM is to be widely adopted, then practitioners such as CNMs need to accurately understand its concepts and also to be afforded the opportunity to exercise professional control over its implementation. Central to an epistemically balanced EBM is the need to ensure that midwifery knowledge contributes in a robust and ongoing fashion to EBM’s scientific research base. Lastly, EBM advocates must identify balanced strategies to both rationally and fairly address consumerist pressures for aggressive health care consumption. 

De Vries R, Lemmens T. The social and cultural shaping of medical evidence: Case studies from pharmaceutical research and obstetric science. Social Science & Medicine 2006; 62(11):2694-2706.

 Abstract: Most critiques of evidence-based medicine (EBM) focus on the scientific shortcomings of the technique. Social scientists are more likely to criticize EBM for it ideological biases, a criticism that makes sociological sense but is difficult to substantiate. Using data from our studies of (1) the influence of pharmaceutical companies on the conduct and reporting of clinical trials, and (2) obstetric science in the
Netherlands (where nearly one-third of births occur at home) we show how the evidence of evidence-based medicine is shaped by forces both structural and cultural. The threats to objective evidence are many, and, if EBM is to be true to its own principles, it must take these threats into account. 

Gordon EJ. The political contexts of evidence-based medicine: Policymaking for daily hemodialysis. Social Science & Medicine 2006; 62(11):2707-2719. Abstract: Policymakers and clinicians increasingly rely on evidence-based medicine (EBM) to make decisions about insurance coverage and clinical treatment. Conflicting value judgments about evidence and pressures exerted by stakeholders render health policymaking a political process. This paper examines how value judgments become embedded in the process of improving medical outcomes by focusing on health policymaking. Specifically, this paper highlights how EBM is variably used as a standard for decision-making depending on perceived risks by policymakers and what is on the competing agenda. I draw upon the case study of the policymaking process for the recent US bill, H.R. 1004: Kidney Patient Daily Dialysis Act, which would legislate daily hemodialysis (DHD) as a new renal replacement therapy modality, and provide federal medicare funding of hemodialysis from 3 to 6 times per week. DHD constitutes an ideal case study with which to explore the political underpinnings of EBM. The interpretations of substantial outcome data showing medical, quality of life, and hypothetical economic improvements of DHD over conventional dialysis are currently being contested in the medical and political spheres. Accordingly, the drive for what some stakeholders view as better evidence through randomized clinical trials is central to the debate and policymaking process. This paper underscores how the demand for, the interpretations, the funding for, and the use of evidence render EBM a political endeavor with vital ethical implications for clinical care.