The idea of
Evidence Based Medicine (EBM) is great. The reality, though, not so
much. Human perception is often flawed, so the premise of EBM is to
formally study medical treatments and there have certainly been some
successes
Consider
the procedure of angioplasty. Doctors insert a catheter into the blood
vessels of the heart and use a balloon like device to open up the artery
and restore blood flow. In acute heart attacks studies confirm that
this is an effective procedure. In chronic heart disease the COURAGE study and more recently the ORBITA study showed that angioplasty is largely useless. EBM helped distinguish the best use of an invasive procedure.
It
is simply no longer possible to believe much of the clinical research
that is published, or to rely on the judgment of trusted physicians or
authoritative medical guidelines. I take no pleasure in this conclusion,
which I reached slowly and reluctantly over my two decades as an editor
This
has huge implications. Evidence based medicine is completely worthless
if the evidence base is false or corrupted. It’s like building a wooden
house knowing the wood is termite infested. What caused this sorry state
of affairs? Well, Dr. Relman another former editor in chief of the NEJM said this in 2002
The
medical profession is being bought by the pharmaceutical industry, not
only in terms of the practice of medicine, but also in terms of teaching
and research. The academic institutions of this country are allowing
themselves to be the paid agents of the pharmaceutical industry. I think
it’s disgraceful
The
people in charge of the system — the editors of the most important
medical journals in the world, gradually learn over a few decades that
their life’s work is being slowly and steadily corrupted. Physicians and
universities have allowed themselves to be bribed.
The
examples in medicine are everywhere. Research is almost always paid for
by pharmaceutical companies. But studies done by industry are well known to have positive results far more frequently.
Trials run by industry are 70% more likely than government funded
trials to show a positive result. Think about that for a second. If EBM
says that 2+2 = 5 is correct 70% of the time, would you trust this sort
of ‘science’?
Selective Publication — Negative trials (those that show no benefit for the drugs) are likely to be suppressed. For example, in the case of antidepressants, 36/37 studies
that were favourable to drugs were published. But of the studies not
favorable to drugs, a paltry 3/36 were published. Selective publication
of positive (for the drug company) results means that a review of the
literature would suggest that 94% of studies favor drugs where in truth,
only 51% were actually positive. Suppose you know that your stockbroker
publishes all his winning trades, but suppresses all his losing trades.
Would you trust him with your money? But yet, we trust EBM with our
lives, even though the same thing is happening.
Let’s
look at the following graph of the number of trials completed versus
those that were published. In 2008, the company Sanofi completed 92
studies but only a piddly 14 were published. Who gets to decide which
gets published and which does not? Right. Sanofi. Which ones do you
think will be published? The ones that favor its drugs, or the ones that
prove their drugs do not work? Right. Keep in mind that this is the
only rational course of action for Sanofi, or any other company to
pursue. It’s idiotic to publish data that harms yourself. It’s financial
suicide. So this sort of rational behavior will happen now, and it will
not stop in the future. But knowing this, why do we still believe the
evidence based medicine, when the evidence base is completely biased? An
outside observer, only looking at all published data, will conclude
that the drugs are far, far more effective than they are in reality.
Yet, if you point this out in academic circles, people label you a
quack, who does not ‘believe the evidence’.
Rigging of Outcomes — Or
consider the example of registration of primary outcomes. Prior to year
2000, companies doing trials did not need to declare what end points
they measured. So they measure many different endpoints and simply
figured out which one looked best and then declared the trial a success.
Kind of like tossing a coin, looking at which one come up more, and
saying that they were backing the winning side. If you measured enough
outcomes, something was bound to come up positive.
In
2000, the government moved to stop these shenanigans. They required
companies to register what they were measuring ahead of time. Prior to
2000, 57% of trials showed a positive result. After 2000, a paltry 8%
showed good results. More evidence of the evidence base being completely
corrupted by commercial interest, and the academic physicians who were
getting rich on it tacitly allowing corruption because they know that
you don’t bite the hand that feeds you
‘Advertorials’ — Or this example of a review paper in the NEJM that
fracture rates caused by the lucrative bisphosphonate drugs were “very
rare”. Not only did the drug companies pay lots of consulting fees to
the doctors, three of the authors of this review were full time
employees! To allow an advertorial to be published as the best
scientific fact is scandalous. Doctors, trusting the NEJM to publish
quality, unbiased advice have no idea that this review article is pure
advertising. Yet, we still consider the NEJM to be the very pinnacle of
evidence based medicine. Instead, as all the editors of the journals
sadly recognize, it has become lucre-based publishing. Mo money = better
results.
Money from Reprints — The reasons for this problem is obvious to all — it’s
insanely profitable for journals to take money from Big Pharma.
Journals want to be read. So they all try to get a high Impact Factor
(IF). To do this, you need to get cited by other authors. And nothing
boosts ratings like a blockbuster produced by Big Pharma. They have the
contacts and the sales force to make any study a landmark. A less
obvious benefit is the fees that are generated by Big Pharma purchasing
articles for reprint. If a company publishes an article in the NEJM,
they may order several hundred thousand copies of the article to be
distributed to unsuspecting doctors everywhere. These fees are not
trivial. The NEJM publisher Massachusetts Medical Society gets 23% of
its income from reprints. The Lancet — 41%. The American Medical
Association — a gut busting 53%. No wonder these journals are ready to
sell their readers (ordinary physicians) down the river. It pays. Who
needs journalistic ethics when there’s a Mercedes in the driveway? Mo
money, baby. Mo money.
Bribery of Journal Editors — A recent study by Liu et al in the BMJ shed
more light on the problem of crooked journals. Crooked journal editors.
Editors play a crucial role in determining the scientific dialogue by
deciding which manuscripts are published. They determine who the peer
reviewers are. Using the Open Payments database, they looked at how much
money the editors of the most influential journals in the world were
taking from industry sources. This includes ‘research’ payments, which
are largely unregulated. As mention previously, much ‘research’ consists
of going to meetings in exotic locale. It funny how many conferences
are held in beautiful European cities like Barcelona, and how few are
done in brutally cold Quebec City.
Of
all journal editors that could be assessed, 50.6% were on the take. The
average payment in 2014 was $27,564. Each. This does not include an
average $37, 330 given for ‘research’ payments. Other particularly
corrupt journals include:
This
is slightly horrifying. Each editor of the Journal of the American
College of Cardiology received, on average $475 072 personally and
another $119 407 for ‘research’. With 35 editors, that’s about $15
million in bribes to doctors. No wonder the JACC loves drugs and
devices. It pays the private school bills. Mo money = we’ll publish your
crooked studies for you. Mo money, baby, mo money.
Publication Bias — The
evidence base that EBM depends upon is completely biased. Some people
think I’m really anti-Pharma, but this is not really true. Big Pharma
companies have a duty to their shareholders to make money. They have no
duty to patients. On the other hand, doctors have a duty to patients.
Universities have a duty to remain unbiased.
It
is the failure of doctors and universities to keep their greedy paws
out of the corrupting influence of Big Pharma money that is the problem.
If Big Pharma is allowed to spend lots of $$$ paying off doctors and
universities and professors, then it should do so to maximize profits.
That is their mission statement. Doctors love to blame Big Pharma
companies because it takes peoples gaze off the real problem — lots of
doctors taking $$$ from anybody who will pay. The pharma industry is not
the problem. Bribery of university doctors is the problem — one that is
easily fixed if the political will exists.
Consider this study.
Looking at studies in the field of neurodegenerative disease,
researchers looked at all the studies that were started but never
finished or never published. Approximately 28% of studies never made it
to the finish line. That’s a problem. If all the studies that don’t look
promising for drug candidates are not published, then it appears that
the drugs are way way more effective than they really are. But the
published ‘evidence base’ would falsely support the drug. Indeed, Pharma
sponsored trials were 5 times more likely to be unpublished.
Imagine
you have a coin flipping contest. Suppose a player call ‘Big Pharma”
chooses heads, and also pays the coin flipper. Every time the coin
flipper pulls up tails, the results don’t count. Every time it comes up
heads, it counts. This happens 28% of the time. Now, instead of a 50/50
split of heads and tails, it’s more like a 66/34 split of heads/tails.
So the ‘evidence based medicine’ lover claims that heads is far more
likely to come up than tails, and castigates people who don’t believe
the results as ‘anti-science’.
Evidence
based medicine depends entirely upon having a reliable base of evidence
(studies). If the evidence base is tampered with, and paid for, then
EBM as a science is completely useless. Indeed, the very editors whose
entire careers have been EBM have now discovered it to be worthless.
Does the CEO of Phillip Morris (maker of Marlboro cigarettes)
smoke? That tells you all you need to know about the health risks. Do
the editors of the NEJM and the Lancet believe EBM anymore? Not at all.
So neither should we. We can’t believe evidence based medicine until the
evidence has been cleaned up from the corrupting influence of
commercial interests.
Financial conflicts of interest (COI), also known as gifts to doctors, is a well accepted practice. A national survey in the New England Journal of Medicine in 2007 shows
that 94% of physicians had ties to the pharmaceutical industry. This
gravy train only rides in one direction. From Big Pharma to the wallets
of doctors. Sure Big Pharma can simply pay doctors directly, and it does
plenty of that. It’s no surprise that medical students with more exposure to pharmaceutical reps develop a
more positive attitude towards them. Many medical schools have limited
exposure of medical students in response, but declined to get off the
gravy train themselves. There is a simple relationship between how
prominent a physician is (more articles published — almost always
academic doctors and professors) and how much money they take from Big
Pharma. Mo prominent = mo money. Further, there is a ‘clear and strong link’ between taking industry money and minimizing the risk of side effects of medications.
What, you thought people teach at prestigious institutions like
universities for the good of mankind? Maybe that’s why they went there,
but that’s not why they stay. They came for the science. They stayed for
the money.
So here’s a damning list of all the problems of EBM
Selective Publication
Rigged outcomes
Advertorials
Reprint Revenues
Bribery of Journal Editors
Publication Bias
Financial Conflicts of Interests
When
the evidence base of medicine is bought and paid for, people die. That
is how doctors have created this opioid crisis that kills thousands of
people. Pharmaceutical companies want to pay off doctors, just as drug
lord want to pay off judges and police officers. Doctors, being human,
should put safeguards against this temptation. Unfortunately, doctors
and universities have been willing participants in this game of killing for profit. We need to end it now. End the corruption of the universities. Stop the bribery of doctors.
Nephrologist.
Special interest in type 2 diabetes reversal and intermittent fasting.
Founder of Intensive Dietary Management Program.
Disclaimer:
This article is not intended to provide medical advice, diagnosis or
treatment. Views expressed here do not necessarily reflect those of
GreenMedInfo or its staff.
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