The problem with evidence-based health is not what you think

I’ve based a huge chunk of my career on the assumption that evidence-based information helps people make better informed health decisions, have better health conversations with their doctors and ultimately leads to better health outcomes.

Evidence is my stock in trade. I have spent many years translating evidence into a form that people can understand. I’ve written thousands of evidence-based articles across many channels. I’ve written position statements, belonged to guideline writing groups and spend many hours in the grand pursuit of evidence.

I really do think evidence-based health information helps consumers and the health system as a whole, or I wouldn’t have chosen to dedicate my medical career to information and communication.

Yet lately the inadequacies with evidence have become more and more glaring to me. Lately it seems to me that we need to start paying better attention to what  evidence can’t do — as much as to what it can do. And I wonder if it isn’t time for a better approach in developing and transmitting health information via any channel.

Evidence, for one thing, doesn’t last. It is a fluid beast — forever slithering under our grasp. Recommendations change over time and there seems to be a growing fuzziness around the edges.

So to take a simple example:  Evidence shows fish oil capsules can reduce triglyceride levels but it doesn’t look like they reduce heart attacks. So should fish oils be recommended for heart health? And in what dose? And how do we communicate those uncertainties?

It seems that for every fact we think we know, there are tens and hundreds, perhaps thousands more we don’t. Much of what I write is peppered with words and phrases like: “may,” “might,” “suggests,” “possibly,” “is likely to,” “there is some evidence for …”

There is a large industry interpreting all this and developing systematic reviews, guidelines and recommendations for practice. This helps a lot.

But it is a reductionist and a little like joining up the dots we think we’ve got and proclaiming we have a giraffe — when all along we have a combine harvester.

Relying on evidence to describe reality for us is like relying on person with vision loss to describe an intricate carving. At best it’s fuzzy and incomplete.  At worst it’s misleading.

But we are working on sharpening that picture — bit by bit. New evidence is published every day. So dropping evidence based medicine is clearly not the answer. It’s important and useful.

But I wonder if an over-reliance on evidence has watered down the intuitiveness and people skills that we have used for millennia to provide unconditional empathy, encouragement, hope and other ingredients for healing. Perhaps these skills need to be brought back to the fore in communicating about health whether in writing, video or in person. Perhaps this will better help help bridge the gulf between evidence and reality.

Instead of making evidence-based recommendations from a position of expertise could it be better to consider what we know about people’s values and viewpoints to see how the evidence best fits them?

Can we become more comfortable in embracing the space where there is no evidence yet? Saying “We don’t know” shouldn’t mean there is no hope. Can we find a way to provide hope in the face of uncertainty — and stand by people whatever they choose?

With or without evidence, it seems so important in communicating about health to foster the capacity within ourselves and within the community to approach medicine and healing with wonder, awe and faith.

So really there is no problem with evidence. The biggest problem is the gap between evidence and reality that only the human side of us can fill.

My hope is when we can transmit the evidence with empathy, love and humility we’ll get better at connecting the right information to the right people at the right time. And then we’ll get better at inspiring people to make healthy decisions — and that should benefit all of us.

Jocelyn Lowinger is a physician in Australia who blogs at Snap: Connect: Inspire.  She can be reached on Twitter @DrJoLow.

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  • Arby

    I agree with you about the personal interaction needed from physicians. For the evidence part of it, you place detractors in the position of being against evidence which would be a lucidness thing. All rational people agree with evidence being used to make decisions.

    There are two problems here and one is with the evidence. It is claimed for large populations, for women and other demographics when only tested on men and its researchers have a vested stake in what the outcomes. These are only a few things, I am sure there are more, that lead me to also concur with your statement about it being fuzzy.

    I can live with fuzzy incomplete knowledge, and if it is just between me and my physician. However, in the real world, I am not sure you realize how brutal the current state of evidence is used and not just by physicians. Whenever we do not fit into the model predicted and dictated to us by the “evidence” we bludgeoned with it. The fuzzy, incomplete logic that is subject to change, now becomes a hard and fast rule that if you don’t obey, even if you have demonstrable harm from it, you are killing yourself, reducing your doctor’s income and respectability, ruining society, causing the death of the economy and I am sure they will work in contributing to global warming somehow. And, never, ever have I seen any evidential body admit they were wrong and they may have caused harm to people, even when the evidence pendulum swings in an entirely opposite direction.

  • Liz

    Since it takes a lot of study and time and critical analysis to understand and apply evidence based medicine, it often fails to serve its purpose. With misinterpretation of ‘evidence’ along with ‘big pharma’ trying to distort the ‘evidence’ actually coming to grips with what the ‘evidence’ is needs quite a bit of research. So the easy way out is to practice what is being ‘loudly’ propagated as evidence. And when somebody who actually has ‘critically analysed’ voices a critique, he is shown the ‘evidence’ by people who haven’t. So there’s talk and there are papers and there are papers about the papers and there is talk of the papers about the papers and…where were we?
    What we need is understanding EBM for what it is. Problem is people who don’t and claim to be practicing EBM.
    And of course there is always CBM and GBM!( common sense based medicine and gut based medicine!) for things which evidence has still to catch up with!

  • DeceasedMD1

    Nice article Dr. L. I have been feeling that way for a long time. The art of medicine is being taken over by this facade-kind of like the emperors new clothes. It really takes away often from critical thinking in an ironic sort of way.

    • Jocelyn Lowinger

      Hi there DeceasedMD1,
      Thanks for your thoughts – I appreciate you taking the time comment.
      All the best

  • Joe

    Evidence-based medicine should be a tool in the toolbox. Instead, it has become an end unto itself. Outcomes seem to be less important as long as you followed the appropriate recipe in the cookbook.

    • Jocelyn Lowinger

      Hi Joe,
      Thanks for your thoughts – I appreciate you taking the time to comment.

  • LeoHolmMD

    Science is a spectrum of inquiry. The results of that inquiry, sometimes referred to as evidence, can have variable quality based on the strength of the investigation. As an example, physics is fairly hard science. Experiments can be done repeatedly and cross validation is routine. The results of physics are rarely flipped, as models are improved over time to reflect observation. For instance, Newtonian mechanics did not become “wrong” when relativity was discovered. The model of reality simply became more accurate and more consistent with observation. Medical evidence is nothing like this. We cannot experiment on humans. It only takes a few small trials before the guideline mongers come out. Cross validation is perceived as nearly unethical. There are strong financial incentives to corrupt the evidence. Medical practice is routinely flipped as yesterday’s cure becomes todays harm. Medical evidence should not be viewed as hard science. It is far closer to a guide for human engagement, as you have proposed.

    • Jocelyn Lowinger

      Dear LeoHolmMD,
      You have highlighted many of the challenges in interpreting evidence. I don’t think we should chuck out collecting evidence – but I think as you suggest we could be using it more mindfully across all types of communications and consultations to inform decision making in the light of individual people and their values.
      Thanks again

  • Jocelyn Lowinger

    Hi Michelle,
    Thanks so much for taking the time to comment. I think you are personalising the evidence to the person and their values will be enormously helpful.
    Thanks again

  • Jocelyn Lowinger

    Hi there Scott,
    Thanks so much for your thoughts. I agree that relying too much on EBM neglects other aspects of medicine. Thanks for taking the time to comment.

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