In The Absence of Evidence…

In this week’s JAMA, Scott Braithwaite, MD, MS wrote a Piece of My Mind editorial, “EBM’s Six Dangerous Words,” which made me think back to a former blog post of mine from 2011, “Doc, can I use this natural supplement?” What I omitted from the original blog post was germane to Dr. Braithwaite’s point.

In academic medicine, we often derate complementary/alternative therapies because of the lack of evidence for their benefits, until they are “proven” to be beneficial. Yet some patients rely on them because of the actual or perceived benefits the therapies provide, as my patient had done.

While I am not advocating the indiscriminate use of uninvestigated treatments in managing patients, I advocate maintaining an open mind about why our patients choose to use the remedies they do. On the other hand, we do not have to recommend or prescribe therapies that have no or little scientific evidence supporting their benefits, as some practitioners often do.

However, in the absence of significant harm, we should restrain ourselves from telling patients to stop or avoid such treatments if our patients feel they gain benefit from them.

“Absence of evidence is not evidence of absence” (Altman & Bland, BMJ 1995)

I have heard students, residents, and colleagues say the very words Dr. Braithwaite decries: “There is no evidence to suggest…” when deciding on treatment or in looking at another physician’s prior decisions when consulting on a new patient. As a clinician educator [and in full disclosure, I have probably said those very words myself], I often respond to their admonishments by citing the infamous Parachute article from the 2003 Christmas issue of the BMJ.

Most of what we do in medicine is unsupported by evidence. We need to keep this in mind as we see patients, especially as we teach and train the next generations of physicians.

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About Ryan Madanick, MD

I am a gastroenterologist at the University of North Carolina School of Medicine, as well as the Program Director for the GI & Hepatology Fellowship Program. I specialize in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD. I can be followed on Twitter: @RyanMadanickMD
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2 Responses to In The Absence of Evidence…

  1. Adrian Born says:

    There is good EBM and there is bad EBM. The difference is open mindedness. Open minded EBM creates a level playing field for alternative therapies if they take up the challenge of proving themselves. However, many do not want to play by the rules but want to make them up as they go along….. http://clinicalarts.blogspot.mx/2013/11/the-alternative-view-of-evidence-based.html

    One of the great contributions of good EBM has been more objective evidence on risks and side effects and their inclusion into the therapeutic risk benefit equation. Where the condition or symptom has little objective benefit in treatment and the medical solution has significant risks and side effects, low yield, unproven alternative therapies may be used first line even when they may be little more than superplacebos. Those few that encourage a culture of independence and health responsibility can have positive personal and cultural effects. An example is the open minded EBM approach to EFT as opposed to the closed minded approach of the sceptic. http://clinicalarts.blogspot.mx/2013/11/wiki-eft-wikis-most-vitriolicly-biased.html

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