ClinicSpeak: evidence-based vs. eminence-based medicine vs. quackery

The current evidence-base does not support any treatments for progressive MS. #ClinicSpeak #MSBlog #MSResearch

"We have had numerous discussions on this blog about evidence-based medicine (EBM) in relation to the treatment and management of MS. The Pharma industry equates EBM with getting a license and being able to market their treatment for a particular indication. Clinicians equate EBM with irrefutable evidence that a particular treatment works and is better than placebo or another treatment; this does not mean it has to be a licensed therapy. Licenses are really about money. What we clinicians use to make a decision is a weighing-up of the evidence; we usually require support from our peer-group before accepting the evidence as being good enough. In other words it is hard to be an outlier when it comes to practicing EBM. The latter is at odds with innovators; i.e. those clinicians who try something based on a scientific rationale or some other reason. We don't want to stop innovation as that is how a large number of advances have happened in medicine. You can usually identify innovators from quacks; their background and motivations for trying something are very different."

"For people with a chronic disease EBM can be frustrating as patients often want treatments that only promise a benefit; they are prepared to take a chance. The medical community is usually resistant to prescribing treatments that only promise a benefit because the scientific rationale is poor, the evidence-base is non-existent, the treatment may be risky or often the people offering the therapy are charlatans who are simply in it for the money."

"One of the main issues I have to counteract in MS is the off-label prescribing of DMTs in progressive MS. An example is alemtuzumab or bone marrow transplantation. The hype around these treatments has led to unrealistic expectations; even in MSers with progressive disease who are aware that the evidence base supporting these treatments in advanced MS is poor. I am continually having to explain to people why these treatments are inappropriate to use without a sound evidence-base in progressive MS. The other reason for push back is the risks associated with these treatments, balanced by undefined benefits. Saying no to my patients is increasingly making me unpopular. What we really need is better trials in progressive MS based on new insights, for example the use of combination therapy strategies, i.e. anti-inflammatory therapies in combination with neuroprotectives and new drugs that may promote remyelination. The problem is the regulators and pharma industry have yet to develop an appropriate and rational development plan for testing combination therapies in progressive MS. I hope the progressive MS alliance will address this issue."

"I read the editorial below in last week's BMJ (British Medical Journal) about EBM in orthopaedics and sports medicine; it made me smile as so much of it is relevant to neurology and the treatment of multiple sclerosis. I have provided some excerpts of you to read and ponder over."

Lohmander & Roos. The evidence base for orthopaedics and sports medicine. Cite this as: BMJ 2015;350:g7835


..... Medicine rests on an uneven evidence base. Some interventions are supported by large multicentre randomised controlled trials that have a low risk of bias and are powered for hard endpoints—a high level of evidence. Others depend on retrospective observational data that provide a lower level of evidence. Yet others were theorised and considered biologically or mechanistically plausible and are heirlooms of “eminence based medicine.”......

..... Some interventions are just plain wrong and have real costs and harms, without countervailing benefits. Medical reversals may occur when well done clinical trials, systematic reviews, and meta-analyses of trials find current practice to be no better than a lesser treatment or placebo. .....

...... Clinical impressions can be deceiving. Where high level evidence speaks against abundant clinical experience and ingrained and unquestioned routine, cognitive dissonance results. Defenders of questioned treatments focus on potential scientific flaws in the published trials to invalidate trial results and thereby to decrease their level of cognitive dissonance, while ignoring the inherent biases of clinical experience and the phenomenon of the physician as a placebo reactor. It was, for example, suggested that participants in sham controlled surgical trials “may not be of entirely sound mind” and research performed on such people “not generalisable to mentally healthy patients.”.....

.... Confirmation bias reigns and we ignore, or do not want to be exposed to, information or opinions that challenge what we already believe, while wanting to hear information and beliefs that confirm what we already believe. This human trait contributes to overconfidence in personal beliefs and maintains and strengthens beliefs in the face of contrary evidence. The effects are stronger for emotionally charged issues and deeply entrenched views. As a result, proponents of questioned interventions fight hard for their interventions and specialties and often delay change, when the appropriate and ethical action would be to abandon ship.....

CoI: multiple

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