Contrary to what most people might think, the primary impetus behind the Evidence-Based Medicine movement is not a noble quest for knowledge or a desire to heal patients, nor is it a desire to bring more rigorous decision-making to the process of clinical medicine or to infuse the care of patients with more science, No. the driving force behind EBM is something more basic, something less noble. If you sit back and really reflect on what drives EBM, you will realize that it is fear. Yes FEAR. Fear on the part of physicians that we are not providing the best care for our patients; fear that the treatments we are giving patients are arbitrary or random; fear that if we do not provide each and every person with the best possible care, we are somehow forsaking our sacred covenant with patients. We are fearful because of the almost unbearable gravity of the decisions we make and of the horrendous and terrifying chasm of uncertainty which dominates so much of medical practice.
And patients are fearful too. They have fear that their treatments are arbitrary or casual. They are afraid that if they came on a Tuesday instead of a Wednesday they might get a different treatment, or that a different physician would treat them differently. They are fearful that if they got treated in a different hospital or in a different city they would be treated differently. They are fearful that their condition might be cured by one physician and not by another. They are afraid that their lives may depend on the whims of individual physicians. Even though the idea is preposterous, they are fearful that their physician may have missed that class in medical school many years ago and their survival will depend on it.
And politicians and managers are fearful too. They are fearful that they will be called to task if they do not have justification for their policies. They are afraid that they will be ridiculed and humiliated by the media if they are not “scientific” and “evidence-based”. And they are afraid that if they do not have “evidence” to back up their decisions, they will lose their careers and way of life. Since they know that everyone will be asking who would be foolish enough to make policy decisions without scientific evidence to back it up? Even if the science is nonsense, at least its still science.
So, we have manufactured a system of scientific evidence which provides a facade of objectivity. And we pretend that it provides us with real answers. Most of us know deep down that the vast majority of it is just nonsense, a charade. Most of us have known all along that the Evidence-based approach could never really answer most of these questions, but we’ve permitted ourselves to ignore it because everyone else is ignoring it and we are fearful that it would lead to subjectivity. We are afraid that the only alternative to the facade of objectivity is a spiral into an abyss of relativity and subjectivity, which will definitely not inspire confidence on the part of our patients. So we have accepted the dogma of quantification and we use tools, most of which are glaringly crude and inappropriate to the task, to analyze complicated medical phenomena as if it were the most natural thing in the world to do. So we assess someone’s quality of life or shortness of breath or burden of disease not in terms of how they feel or experience it, but rather in terms of numerical measurements, which allow us to manipulate the results statistically. Deep down we all know that medical phenomena is much too complicated for simplistic quantitative measures, that we are seeing only the shadow the phenomenon we are trying to study. But we accept it as objective and true and reliable.
But it all derives from one basic human emotion: FEAR