Friday, November 11, 2016

Dying to Wait

Evidence Based Medicine.  A guide that all medical professionals are to aspire to.  But what exactly does evidence based medicine currently mean?  After listening to Timothy Caulfield's talk at the Perspectives in Exercise, Health and Fitness conference 2 weeks ago, I am left with the impression that there is absolutely no evidence for almost everything I do.  Not even supplementing vitamin D in the winter!

Mr. Caulfield is an author and professor of health law at the University of Alberta and he is a very outspoken critic of Naturopathic Medicine.  He was certainly entertaining to listen to and fortunately a lot of what he said about celebrity health fads was true.  Unfortunately, if there is not a body of research consisting of randomly assigned, double blinded, placebo group, clinical trails showing significant benefit, Mr Caulfield was quick to state, "no science".

This leaves no room for logical conclusions in the absence of clear research evidence.  Two of the many examples Mr. Caulfield cast away as, "no evidence" were: prostate cancer screening and cupping.  Delving into each more closely will demonstrate that concluding "no evidence" based on the results of research alone may be problematic.

Looking at prostate cancer screening, according to the research the net benefit is zero.  However, Ben Stiller may be right too.  Research tells us that if the lives of Ben Stiller and 100 other men are saved from early intervention from prostate screening (PSA) and the lives of 90 other men are lost (due to complications of prostate surgery for example) the net gain is small.  And yet logic concludes that the 100 men who's lives were saved by prostate screening are very happy for the PSA test.  So do we throw the test away?  This is one of the complexities of research guided medicine.  In this case, medicine does not have the tools to know which side of the fence each male tested will be on.  In the mean time, PSA screening may be better as an individual choice after the risks have been described but "no evidence" is an illogical conclusion.

Then we have Michael Phelps to thank for bringing cupping to the general public's attention.  How can a research trial with a placebo group ever be done on cupping?  It leaves circular marks!  Again, do we discard cupping as a celebrity fad?  I should hope not as cupping has provided some people benefit long before Michael Phelps used it.  In this case, I would propose we take a look at our scientific understanding of muscle physiology and fascia tissue structure and then connect that to the clinical effect we see after cupping treatments on patients.

I fail to see how this logical approach makes Naturopathic Medicine quackery (which was a term originally used for medical doctors who used mercury as a remedy).  As a Naturopathic Doctor, I do not always have the luxury of waiting for double blinded, randomly assigned, placebo group, clinical trials.  Suffering people are often in my office after being told there is nothing that can be done for them (except possibly manage symptoms like pain).  "Nothing that can be done" is another way of saying there is no studies to the standard Mr. Caulfield (and I suspect many conventional thinkers) deem as science.  In these cases, I could sit on my hands and do nothing.  Alternatively, I could use the best evidence available to me at the time which would include a mix of research, physiology, and clinical experience.  It would also be my responsibility to develop a common understanding of my assessment and arrive at a shared treatment plan with my patients.

There was "no evidence" that BPA was dangerous to our children for years.  Research demonstrated this.  And then Canada became the first country in the world to take BPA out of baby bottles and toys as BPA was finally recognized as a hormone disruptor.  What damage was done while the science finally caught up?  Science often just confirms what we already know to be true as there is still so much that science knows so little about.

I understand that there must be a balance between potentially risky early adoption of medical treatments and on the other side latent adoption where great numbers of people suffer unnecessarily and are dying to wait for the wheels of science to spin on and on.  It is equally as important to have this conversation as it is to know what current research evidence says.