“There is a pressing need for a wide-ranging review of the nature of evidence” College of Medicine

February 13, 2011
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Ten years ago while doing my masters in health promotion I applauded David St George, Consultant/Senior Lecturer in. Clinical Epidemiology and Public Health Medicine at the Royal Free Hospital in London when he said ”The time has come for complementary medicine to turn away from the need to obtain legitimacy from orthodox medicine by adopting its paradigm and research methods”

Since 70s when Professor George Engle and Ivan Illich et al  questioned the reductionist  biomedical model of assessing  health and focusing on the treatment of symptoms there has been a polarised debate on how evidence should be used in clinical practice. In fact it would appear Chiropractic sceptics only realised there was a debate until recently thinking quantitive studies and the randomised controlled trial were the only acceptable evidence to demonstrate the efficacy of a clinical intervention.

tyranny_-_montesquieuUnfortunately the biomedical wing of the chiropractic profession shared this view, not understanding the difference in assessing the effectiveness of a drug and assessing the effectiveness of an intervention dependent on the skill of the practitioner like surgery or a chiropractic adjustment. The BCA presented their “plethora of evidence” to Simon Singh and made the chiropractic profession a laughing stock. Interventions relying on the skill of the practitioner are more suited to qulaitive investigation and there needs to be a review of how evidence is interpreted, before The “Tyranny of Evidence” which David Sacket was afraid disrupts clinical progress.

Skeptics like Edzard Ernst, Simon Singh, Blue Wode the Editor of EBM first and David Colquhoun are really getting their nickers in a “twitter” because the College of Medicine believe there is a “pressing need for a wide-ranging review of the nature of evidence required to inform clinical practice, and intends to commission such a review”. This is what the College of Medicine have recently published on their website.

I would urge all interested parties to get on Twitter and follow these “skeptics” to understand where their narrow understanding of “ scientific evidence” is coming from.

Perspectives on Evidence

http://www.collegeofmedicine.org.uk/perspectives-evidence from the  College of Medicine

Professor Andrew Miles & Dr Michael Loughlin, Science Advisory Council

The College of Medicine believes there is a pressing need for a wide-ranging review of the nature of evidence required to inform clinical practice, and intends to commission such a review.

Evidence is information that provides justification for a belief or action. It gives us a reason to adopt a belief (e.g. stomach ulcers are caused by H. Pylori bacteria) or choose a certain course of action (such as prescribing inhaled steroids to patients with asthma.)[3]

For information to become evidence, you must have:

• a description of the background situation – the context in which the problem occurs

• a clear explanation for regarding certain features of that context as problematic

• an inquiry with the goal of addressing the problem.[4]

Evidence can be acquired by careful observation, but the facts never speak for themselves[1].  Observation is an activity carried out by people in conjunction with other activities – questioning, categorising and hypothesising – in order to frame broad pictures of the world against which these activities acquire meaning. Information is not evidence without a theoretical structure determining which inferences are valid and which are not [1,4].

We recognise features of the world as problematic because we value certain outcomes over others. Illness is problematic because it is bad, and attempts to reduce the value-laden aspect of this claim to a purely descriptive or empirical one are unconvincing. Just as statistical analyses of what is usual and unusual do not capture the meaning of the claim that high intelligence is in itself a good thing and low intelligence a bad thing.[4]

Similarly, we characterise evidence as strong or weak depending on how ‘convincing’ it is, but it is crucial to note that ‘convincing’ is not a descriptive or empirical term. It implies the exercise of judgment. It concerns not what people do believe but what they should believe – a person can ignore the evidence, but to do so is irrational. Evidence is an evaluative concept: a person lacking the ability to make evaluative commitments could have no reason to choose any belief or course of action over any other. What this means for clinical practice Deciding what is good evidence involves making value-judgements. Human reasoning is a value-laden process. So the concept of ‘objectivity’ as a purely empirical, neutral, inquiry is not a sustainable model of good practice or the proper use of evidence. This false assumption can lead researchers – and those using scientific research – astray.[4]

There are alternative definitions of objectivity that are an essential component of sound reasoning and good practice.[4] Objectivity seen as the ability to recognise a plurality of reasonable positions on a given question, including ones based on theoretical and evaluative assumptions different to your own, is an essential skill of the good practitioner.[3] The clinical encounter is an encounter between people,[5] and a reasonable person recognises that alternative positions may be taken by colleagues and patients. He or she engages with colleagues or patients to understand those positions.[2]

The idea that there can be any one type or source of evidence that is always better than any other seems difficult to sustain, for two reasons. First, the vast range of contexts that can be reasonably interpreted as problematic for human health and well-being. Second, the diversity of values and frameworks that can come into play in identifying and characterising those problems.[1,2] We make evaluative and theoretical assumptions whether we own up to them or not. So an intellectually honest approach to evidence and reasoning will involve being as reflective and open as possible about one’s own assumptions.[3]

Without a recognition of the relevant context, theory and reasoning applied to a particular problem, EBM is merely Information-based medicine.[2] These frameworks are necessary to bridge the gap between information and conclusion.[6]

There may be such broad agreement about the undesirable nature of certain physical conditions that it is absurd to question whether they are serious problems. Even so, it is a serious error to ignore or deny the significance of the theoretical framework around that problem.[4] This can lead to a refusal to accept that there is scope for reasonable disagreement about which theoretical frameworks or values to adopt.[1] If we are to avoid dogmatism then we need to remain aware that even our most common and entrenched pictures of the world and our place within it are in principle open to revision [3] – just as we have realised that stomach ulcers are caused by bacteria, not acid burning the lining of the stomach.

The skills of acquiring and utilising information from systematic research are essential but the proper use of evidence goes beyond this. We need to cultivate reflective, well-rounded practitioners, who are able to make intellectually defensible judgements about a range of theoretical and value perspectives. They must be aware of the possibilities of different ways of characterising situations and the nature of health problems. Only then do we move beyond promoting know-how to promoting wisdom in practice.[7]

This is a complex challenge. It means good professional education requires awareness of a range of approaches.[8] This requires a fundamental shift in our way of thinking about the relationships between evidence, information from scientific research, expertise, reasoning, clinical knowledge and good practice. A new definition of medical practice as a human activity and the clinical encounter as a relationship between people, acknowledging the beliefs and value judgments these people bring to the consultation.[2,5,6]

The difficulty of the challenge is not a reason to shy away from it.[9] The College of Medicine will commission a full-scale review on the nature of knowledge for clinical practice. We plan to create an international group of distinguished scholars, and will publish its findings in order to engage professionals in this important debate. The review will be led by Andrew Miles, Professor of Clinical Epidemiology and Social Medicine at the University of Buckingham, and co-ordinated from that institution, entering its planning stage in January 2011. Further information on the methodologies to be employed and the expert members of the review group will be available at that time.

1. Loughlin, M (2009) The basis of medical knowledge: judgement, objectivity and the history of ideas, Journal of Evaluation in Clinical Practice 15 (6) 935-40

2. Miles, A, Loughlin, M & Polychronis, A (2008) Editorial Introduction and Commentary: “Evidence-based health care, clinical knowledge and the rise of personalised medicine”, Journal of Evaluation in Clinical Practice 14 (5) 621-49

3. Loughlin, M (2002) Ethics, Management and Mythology, Radcliffe Medical Press, Oxon.

4. Loughlin, AJ (1998) Alienation and Value-Neutrality, Ashgate, Aldershot

5. Henry, S (2010) Polanyi’s tacit knowledge and the relevance of epistemology to clinical medicine, Journal of Evaluation in Clinical Practice 16 (2) 292-7

6. Tonelli, MR (1998) The philosophical limits of evidence-based medicine, Academic Medicine 73 (12) 1234-40

7. Maxwell, N (2004) Is Science Neurotic? Imperial College Press, London

8. Miles, A (2009) On a Medicine of the Whole Person: away from scientistic reductionism and towards the embrace of the complex in clinical practice, Journal of Evaluation in Clinical Practice 15 (6) 941-9

9. Tonelli, MR (2010) The challenge of evidence in clinical medicine, Journal of Evaluation in Clinical Practice 16 (2) 384-9

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Related posts:

  1. Chiropractic vs. Medicine for Acute LBP: No Contest. What a surprise.
  2. Another little pearl from Edzard Ernst
  3. Richard Brown Vice President of British Chiropractic Association argues that the criticism of his profession is wide of the mark
  4. Whats the difference between confirmation bias and just being biased.
  5. The chiropractic profession has not been very effective at defending itself from sceptics
  6. Incompetent leadership unable to put Ernst down.
  7. Despite the damage done by the BCA the chiropractic profession should not seek “legitimacy” through the biomedical model
  8. How can Edzart Ernst be considered an expert on clinical Chiropractic?
  9. BCA and GCC member David Byfield would seem to concur with Simon Singh that the BCA were making bogus claims about the efficacy of chiropractic
  10. Vacancy for a former medical doctor who did a bit of Woo on the side.

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  • JRM

    LMAO!

    How do you imagine you come over with your little hissy fit of a comment? 

    It’s Professor Colquhoun, by the way.

  • Caman

    A fanatic is one who can’t change his mind and won’t change the subject.
    – Winston Churchill  This so reminds me of you Mr Colquhoun.  You are of course welcome toyour opinion but my god you come over as such a narrow minded bigot

  • http://www.chiropracticlive.com/ Richard Lanigan

     Andy is it so hard for you to admit when you are clearly wrong and don’t know what you are talking about. You state:

    “Let me make my position clear. I am not saying that people are not free to make their own choices in care and treatment when it comes to cancer”.

    Thanks for that, so “your position” is: cancer patients are “free to chose” the treatment they want, but we should not, because in your opinion:

    “Those with cancer are not in a position to be good consumers of health care choices. Informed consent and measured choice is difficult to achieve when the overbearing pressure of imminent death looms. The allure of another chance, no matter how slim, will always drive towards the futile”

    They are you words correct me if I am wrong is this not your position on the subject you are blogging about.

    Can you not see how patronising and insulting these comments are to people who are terminally ill. Cancer is a physical illness it does not mean we become stupid and gullible overnight and need a merry band of sceptics to protect us from snake oil salesmen.

    You say “The Cancer Act is a deliberate attempt to ensure that the choices made are more likely to be mediated and assisted by professional people whose job it is to understand cancer and what treatments are available”

    This comment made me laugh because I know what you are thinking. In fact I am writing a book about this.  Who are these people whose job it is to “understand cancer”, probably the best in the health service are the MacMillan nurses, but  without a shadow of doubt the people who understand cancer the best, are the people who have cancer. Understanding cancer has littler to do with treatment and evidence and you comments just show your ignorance of the subject.  

    Then your hole gets deeper when you state “The Penny Brohn Centre is famous for changing its name a number of years ago after a study showed that women attending there had worse outcomes” Do you ever feel embarrassed when you spout absolute crap. Is that why you think they are famous for?

    The Bristol Cancer Cetre changed their name to the Penny Brohn Centre in tribute to their founder Penny Brohn who died in1999. The Penny Brohn centre does not charge people so its not ripping any body off, which kind of does blow a hole in your theory.  The centre does not talk about curing cancer, they talk about empowering people to live with cancer. Dont you think its important for patients to have “experts” help teach others how to live with cancer. I was there for three days during the Summer, its not for me, for reasons I wont go into here (read my book) . However I am in no doubt the vast majority of people do get  enormous help from the centre.

    The study you refer to did not compare like with like. The vast majority of people who go to Penny Brohn are terminally ill, they have been told by there doctors there is nothing more to be done. I was in a group of 12, I was the only person not terminally ill). There are told to go home and get their affairs in order. Think about it, a lot of  people who present to the NHS are stage 2,3 with vast better survival chance than those who go to Penny Brohn. This was an appalling piece of research, I don’t know of any credible oncologist who would quote from it. I suppose skeptics my not have the training. Oh dear ad hom attack, just slipped out.

    So it is not surprising to someone with an MSc in Health Promotion (Brunel); “that patients choosing to attend the BCHC did not gain any substantial survival benefit” then researchers asked “Whether quality of life is enhanced is yet to be answered”

    If you knew anything about this subject you would know, that most medical cancer centres now recognise that the Penny Brohn approach does in fact improve “quality of life” and they are now offering complementary therapies, diet and exercise to their patients as Penny  advocated to my mother back in 1988. As presumably is this guy you have tried to belittle in your blog post.

     As a matter of interest, do you completely reject the current medical approach to treating cancer. Because restricting treatment to RCT evidence,  would practically eliminate surgery, not sure chemotherapy passes the skeptic tests level of certainty, for it to be considered an effective treatment for cancer. Then there is experimental treatment, based on a theory, would sceptics allow that?

  • Richard

     Check out this extra ordinary comment by Skeptic Andy Lewis on his blog; “Those with cancer are not in a position to be good consumers of health care choices. Informed consent and measured choice is difficult to achieve when the overbearing pressure of imminent death looms. The allure of another chance, no matter how slim, will always drive towards the futile”.http://www.quackometer.net/blog/2012/03/the-totnes-cancer-health-centre-a-quack-pascals-wager.html#comment-17292

    This is my response

    Andy to say that is absolute rubbish, to say something like that I dont believe you have met many terminally ill people. The ones I know, and I know quiet a few, would be furious to be told “we dont think you can be a good consumer of health care” . In fact I would go as far as saying, your view is contrary to the entire approach to cancer care in the health service. I am sure there are people who get ripped off by fraudsters, they do tend to get prosecuted by the police. If you have evidence of charlatans operating in the UK offering misleading information about curing cancer lets hear it? This is not a common occurrence in the UK as you seem to be implying. The experience of cancer is different for everybody but your comment is insulting and ill informed. One of the best cancer centres in the country for teaching people how to live with cancer is the Penny Brohn Cancer Centre in Bristol. I spent three days there during the Summmer, guess how much it cost for three days £1,000, £500, £0. 0£ thats how much, they are a charity providing a service for terminally ill people which is not available anywhere else. No one is being forced to goi there against there wishes and they are not going there expecting to be cured. They do want to be empowered to be able to live with cancer and it does that very well.
    In a months time I finish chemo, no one knows whether my cancer will return, I have a 50/50 5 year survival which my doctors believe has been improved by 6 months of chemo.What should I do now to stack the survival odds in my favour. Listen to family and friend who have found this ordeal hardest to deal with and let them decide on what I should do to try and prevent the cancer returning. They are the ones who are desperate for a cure and most likely to get ripped off. You see dying is easy, its harder for those who are left behind and usually they are the ones most scared. My young kids are the ones who have helped me most through this, their world does not stop because I have cancer. My five year old asked me if she could have my lap top if I died. It made me laugh. Shit happens and you get on with it, you dont become an idiot incapable of making decisions because you have cancer?

  • richardlanigan

    Shock horror medical people making claims about hip prosthetics without clinical trials.
    http://www.bbc.co.uk/news/health-17192520  I wonder how the skeptic community will react to this news which effects 50,000 patients. Perhaps they are just prejudiced against CAM practitioners and there anger has nothing to do with clinical science

  • richardlanigan

    Shock horror medical people making claims for the efficacy of hip prosthetics http://www.bbc.co.uk/news/health-17192520 I wonder if the skeptic community is going to be consistent and attack the people who made these claims. 

  • Oceanblue

    Winston speaks to Skeptics!

    A fanatic is one who can’t change his mind and won’t change the subject.

    Man will occasionally stumble over the truth, but most of the time he will pick himself up and continue on.

    Well said Winston

  • http://www.chiropracticlive.com Richard Lanigan

    If you think they are bad here you should follow some of them on Twitter.

    Sometimes I make an effort and you think they are beginning to understand and some chiropractor sets fire to his practice in some hick southern state and they are off again. Sometimes you have to agree to disagree, skeptics dont speak out language we dont speak theirs and leave it there and get on with you life.

  • Oceanblue

    The above appraisal of the situation regarding evidence is the most honest cogent piece of writing I’ve read in a long time. I do despair of childish irrational attitude shown by some commentators on these threads. It seems they do not want to enter into a mature debate about a new emerging health paradigm because it contradicts the narrow rather biggoted one they they cling to. I’m told that at one time man thought the earth was flat and that some men still do which category do the skeptics fall into i wonder?

  • http://www.chiropracticlive.com Richard Lanigan

    David Colquhoun has pointed out on Twitter that he resigned from the Royal Society of Medicine over their inclusion of John McTimoney on the Royal Societys “Roll of Honour” . I was surprised to hear this as John McTimoney started the college because of the medical direction AECC was taking chiropractic. I would love to know from someone who knew John McTimoney would he have been pleased to be on the Roll of Honour of the Royal Society of Medicine or is it another example of chiropractic politicians sacrificing principles in their efforts to gain respectability on the alter of medicine.

    This is what David Colquhoun wrote om his blog about the matter

    The Royal Society of “Medicine”? A twitterstorm broke out when it was noticed that a chiropractor, John McTimoney, had appeared on the Roll of Honour of the Royal Society of Medicine (RSM). Chiropractic is a form of alternative medicine that has essentially destroyed itself after attention was focussed on its claims after the foolish attempt to sue Simon Singh. McTimoney chiropractic is one sect of the chiropractic cult which has appeared on this blog. Quite a bit has been written about it here.

    Many comments quickly appeared on the RSM web page pointing out the absurdity of having a chiropractor on the RSM’s Roll of Honour. An hour or so later, all the comments had been deleted. I wrote to the RSM’s president so ask the reason for this wholesale censorship. Shortly afterwards the web site was altered so ir now says

    The Royal Society of Medicine has been made aware of a number of comments made by RSM members and others, regarding the inclusion of John McTimony on the Wall of Honour.

    In response to these comments the Society is reviewing the situation and will announce the result of the review on the RSM website by November 18th.

    Anyone who wishes to express a view should email development@rsm.ac.uk

    .Luckily, though, two snapshots of the pages before deletion of comments were captured, here and, a bit later, here. Some, including my first comment, were missed, but there are quite enough to give the idea (more on the JREF site).

    The fact of the matter is that the RSM’s Roll of Honour is nothing to do with honour. It is a receipt for a payment of £2500 to the RSM. This time their rather dishonourable fund-raising gimmick misfired badly.

  • http://www.chiropracticlive.com Richard Lanigan

    Hi David,
    Did you know the Royal Society of Medicine also accepts “quacks” as members. Thanks for pointing out about the link to the “College of Medicine” and I have removed their “royal” charter

    I had already included a link to your posting on DC Science so I was well aware of what you thought of this college. I did assume they were “Royal” due to Price Charles involvement, as there is no “Royal College of Medicine does it really matter, I am a republican.

    I did not confuse them with the Royal Society of Medicine or the Royal College of Physicians or The Royal College of Surgeons as you suggested on Twitter.I am sure a few of the GCC medipractors are fellows in the society of Medicine possibly fellows. I probably could have added a few comments of my own to your posting. However I fully support the question the College of Medicine has raised about evidence.

  • Pingback: Tweets that mention “There is a pressing need for a wide-ranging review of the nature of evidence”: Royal College of Medicine -- Topsy.com

  • http://twitter.com/david_colquhoun David Colquhoun

    Oh dear, oh dear,
    Your link is broken but it appears that you have confused the “Royal College of Medicine” with the newly-formed (and misleadingly named) “College of Medicine”. They are very different organisations. The latter is simply the reincarnation of the late Prince’s Foundation for Integrated Health, and organisation that did so much to spread medical misinformation before it folded. You can read all about it in “Don’t be deceived. The new “College of Medicine” is a fraud and delusion”, at http://www.dcscience.net/?p=3632

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