6 arguments from opponents of doxmed that are worth arguing

I have to deal with different opinions about evidence-based medicine. As a doctor who practices this approach, I myself admit that it is not ideal. However, at the moment this is the best that anyone can offer.

In this article I will comment on the most popular criticisms of evidence-based medicine and try to dispel common myths.

1. Dokmed is just a new buzzword

Evidence-based medicine is an approach in which doctors rely on scientific evidence to make their decisions. And this is not a tribute to fashion, but a reflection of scientific progress. Today, evidence is present in absolutely all spheres of life: economics, sociology, marketing and others. Scientific methods are universal to all fields.

In medicine, this means relying on the results of studies that evaluate the effectiveness of a certain treatment, the appropriateness of a particular diagnosis, and the influence of risk factors on diseases.

The big difference between modern evidence-based medicine and the medicine of the last century is that previously there were no such powerful technologies that made it possible to conduct large-scale research relatively quickly and disseminate its results.

Now we, doctors, can not take the bait on unfortunate patients, but use research data to suggest how this or that treatment will work.

2. Dokmed is expensive

Some may say: “Well, of course, doctors in the capital can afford to practice medical medicine, but what should a doctor from the outback do?” Yes, we are all in different conditions: we work in different countries and clinics, with different levels of access to certain information.

But in order to practice dokmed , you don’t need much – just desire and access to the Internet. Medical databases, clinical guidelines, scientific journals, conferences – almost everything is freely available.

Yes, some evidence-based treatments may not be available to all patients. Both financial and geographical factors play a role here. But the good thing about evidence-based medicine is that it allows us to make the best decisions in the conditions in which we find ourselves.

Dokmed is not about practicing expensive, ultra-modern treatment, but about making the most appropriate decisions that are adequate to reality.

I know that conditional doctors in the regions sometimes perform unnecessary actions. For example, they prescribe physiotherapy, which in most cases is absolutely useless, or force patients to spend money on “ bullshit ”. All this could have been avoided if doctors were more likely to focus on an evidence-based approach.

3. Dokmed does not take into account the doctor’s personal experience

The triad of evidence-based medicine – what this approach is based on – says that in making our decisions we should rely on:

• to the best existing evidence;
• clinical experience of a physician;
• patient preferences.

Therefore, evidence-based medicine in no way excludes the clinical thinking of the doctor. On the contrary, it helps strengthen it. After all, when you read published studies that include different subgroups of patients, and then see patients from different subgroups in reality, you can coolly compare these two facts, strengthening your clinical insight.

Yes, there are situations when the best evidence is the doctor’s own experience . After all, even now not everything is covered by research. In these situations, you can only use your clinical thinking, which you developed at medical school and in practice. But this applies mainly to super rare cases.

In all other cases, the use of published evidence only enhances the physician’s practice.

For example, I have been in the field of oncology for a total of 10 years. But neither my practice nor the practice of other oncologists who have worked in hospitals for 30–40 years is enough to take into account all the variety of situations and choose the truly best treatment option. To do this, you need hundreds of thousands of patients to pass through you.

Therefore, the use of evidence base seems very inspiring to me: thanks to it, I can see patterns in the course of the disease and offer the best treatment, even if I have not seen such a huge flow of patients.

In addition, when we say that doctoral medicine cancels the doctor’s experience, we oversimplify its concept – we reduce it to some kind of abstract algorithms. Yes, when choosing a treatment you rely on evidence, but before that you need to form an impression of the picture of the disease. And for this you need to have the same clinical thinking and observation that can only be developed with practice.

4. Dokmed cuts everyone’s hair with the same brush

Yes, there are situations where you need to work according to a template. This approach is especially relevant for emergency medicine : there is no time for thinking.

And yes, some doctors really make a mistake by prescribing the same treatment, even when it is not justified. But any doctor is, first of all, a person who has his own distortions. Some people are simply used to working in a certain way, their brain follows the path of least resistance. But here the question is not for the doctor, but for the doctor and the system in which he is forced to work: is he constantly studying, what kind of work and rest regime does he observe? Of course, when you receive 50 people a day and 10 minutes are allotted for each, it’s difficult not to slip into automatism. And this is a question for the system.

But the very concept of doxmed leaves a lot of room for scientifically based individualization of treatment.

After all, firstly, we take into account patient preferences . Secondly, we have special statistical analysis methods that allow us to evaluate the effectiveness of a particular treatment in different subgroups. For example, how the drug works for patients older and younger than 60 years old, with a more or less complex course of the disease, is being studied separately. That is, there is room for individualization in evidence-based medicine, and this is great.

5. Dokmed slows down treatment

There is an opinion that the evidence-based approach, due to the necessary testing phases, slows down the introduction of the drug to the market. This is true, but in this case I am a supporter of bureaucracy.

Let me explain how this process works .

1. At the first stage, the drug is tested on cell samples and animals – the optimal, most effective molecule is selected.
2. Next, studies are conducted on a small group of patients to determine the optimal dose of the drug.
3. Next, the effectiveness is assessed. To do this, patients are divided into different groups: one is given a new drug, the other is given standard treatment. Then the results are compared. Sometimes this takes years – because you have to wait for the outcomes and register them.

If the drug has shown positive effectiveness, it is sent to regulators – in the USA, for example, this is done by the FDA commission. They study the research, evaluate the evidence, and decide whether the drug will reach the market or not. This is a very long process. And only a small number, about one percent, of drugs that work on cell lines or animals will ultimately successfully pass all stages.

It is worth saying that regulators have accelerated programs for the removal of life-saving drugs. That is, it happens that a drug enters the market immediately after the second stage of testing and begins to be actively used in the clinic. However, sometimes it then has to be recalled because, based on the results of large-scale studies that were carried out after preliminary tests, it turns out that it is ineffective. Or, what’s worse, it’s completely toxic .

History already knows examples when the premature release of a drug played a cruel joke on people. For example, we can recall the thalidomide tragedy.

Pregnant women were massively prescribed Thalidomide, which was supposed to calm the nerves. But its tests were carried out poorly, and in the end it turned out that it disrupts the formation of fetal blood vessels, as a result of which children are born without arms and legs.

Therefore – no. It is impossible to bring a drug to the market without all checks.

6. The research on which DocMed relies is not so objective.

Many, when criticizing medical science, talk about the conspiracy of pharmaceutical companies and the fact that the research they sponsor cannot be objective – the results are supposedly bought. But in fact, the drug registration process is very transparent.

The pharmaceutical company sponsoring his research publishes the protocols in the public domain in advance – for example, what hypothesis the scientists are going to prove, which patients they will include. In addition, at all stages of checks there are independent observers who assess the validity of this study. Next, the regulators, which I mentioned above, come into play.

But even if you and I don’t believe the published study, data from real clinical practice appears after the drug has entered the market. In different countries, different doctors use it to treat patients and share their observations about how it works, that is, they publish their independent studies. We can also read them in the public domain and compare the results.

The important thing here is that pharmaceutical companies, especially large ones, work for a long time and value their reputation very much. They won’t publish a positive study on an ineffective drug. Imagine: all the clinics in the world start using it and face the fact that they were deceived. Trust will be destroyed and the reputation of the big pharma company will be completely destroyed.

This does not change the fact that there are unscrupulous pharmaceutical companies . It can sometimes be difficult to distinguish one from the other; here you need to use critical thinking.

Another point: clinical recommendations. This is a summary of the research results, which were summarized and simplified by the expert group.

Cleanrecs are read more often than primary sources. And here there is a problem: they are not always well made, and sometimes corruption schemes are involved in their publication.

Therefore, ideally, a doctor should read primary sources and practice the skill of critically reading medical statistics – this is as important as the skill of examining a patient. So far, this does not happen everywhere and not always. But this culture is gradually being introduced, and I believe in a bright future. Evidence-based medicine, with its reliance on research, remains the best way to make decisions.