EBM and Medical Power:
Outline Sketch of a History Waiting to Be Written

By Howard Brody

In the Winter 2004 issue of Medical Humanities Report, Elizabeth Bogdan-Lovis analyzed evidence-based medicine (EBM) from the standpoint especially of the interface between the medical “consumer” and the health care system. She looked, for instance, at patient choices to adopt more technological approaches to childbirth in the face of good medical evidence showing that these approaches are worse than the more “natural” methods. As the patient is today left out of all too many discussions of EBM, this analysis was welcome. I suggest here that in order to take full advantage of Bogdan-Lovis’s suggestion—that we must always remember the “distribution of power in social relations”—further work on the history of EBM is required. I will only be able here to sketch a vague outline of a work that I believe will ultimately be illuminating.

My own vantage point (or “habitus” as the anthropologists would have it) is that of an academic family physician. We FP’s may look to the general public like standard, card-carrying members of the medical establishment. (A recent survey showed that a substantial number of patients receiving care routinely from FP’s did not know that FP was the specialty designation of their personal physician.) Among ourselves, we know that we are a member of what one of our early leaders called a “counter-culture.” In one aspect of our existence we are physicians. In another we share something with midwives and nurses, who see medicine close-up but are not part of it, and so can be especially critical of medicine.

I propose that it makes sense to view EBM as the second-most-successful recent challenge to the hegemony of Flexnerian medicine.

“Flexnerian medicine” is, very briefly, the medical worldview that came to characterize the life of the academic medical center in the last half of the 20th century. It is “Flexnerian” in the same sense that we often criticize the Freudians for forgetting what Freud actually wrote. Its advocates always genuflected in the direction of the 1910 Flexner Report, but few of them actually read the report (which actually opposes trying to make medical students memorize large quantities of basic science facts). Flexnerian medicine contained two key assumptions about authority. The first was that the highest level of medical knowledge came from studying the smallest and most basic level of organization. Lab bench research aimed at the cellular or molecular level was “real” medical knowledge and all other forms of research, including clinical trials, were derivative and relatively less satisfactory. It followed from this that the sort of medical practitioner whose work most closely resembled that of the lab bench researcher was the best physician. Such a physician was always a narrowly focused subspecialist. Only the physician who specialized in a single organ system (or ideally a single organ) could know the basic science of his own part of the body with sufficient expertise to apply real medical wisdom at the bedside. When George Engel proposed his biopsychosocial model of medicine in 1977, he referred to Flexnerian medicine as the “biomedical model” by contrast.

An essay by Lewis Thomas, a pathologist, became the “foundation myth” of Flexnerian medicine during the later decades of the 20th century. Thomas recalled how iron lungs were sent to the junkyard in huge numbers in the years following the introduction of the polio vaccine. He described the vaccine as real medical technology, and the iron lung as “half-way technology.” Real technology came from the study of cells and viruses in the laboratory under the microscope. Before we have real technology, we are stuck with halfway measures that somewhat ameliorate the downstream consequences of the disease but do not prevent or “fix” the disease in any fundamental way. Thomas suggested that almost all of medicine in the late 20th century was half-way technology, poised in the next few decades to be replaced by real technology as his fellow lab bench scientists came up with the new basic discoveries. The picture was so appealing to generations of physicians that no one asked why the polio vaccine story was such a rarity, and where the other success stories like the polio vaccine were to be found.

Various movements arose beginning in the 1960s to challenge the authority of Flexnerian medicine. The first, implicit in the structure of MSU’s College of Human Medicine in its early days, was the inclusion of the social and behavioral sciences alongside the biological sciences as the so-called “basic” medical sciences. Shortly afterward came the push toward including ethics and humanities into the medical curriculum. The 1970s saw demands to include the new specialty of family practice, and new programs in primary care internal medicine and pediatrics, in the academic medical center as antidotes to excessive specialization.

These counter-movements made little real impact on Flexnerian medicine. A few courses were added into the periphery of the medical student’s training, along with a clear message that the content of those courses was less important than “real” medicine. A few new residency programs were begun, again with the clear (even if implicit) message that those who elected to complete those residencies were less credible physicians because of their choice. Subspecialist physicians still made the big bucks and won the most prestige, while lab bench research still got the most respect and the most funding.

Later, toward the end of the century, two movements arose that much more successfully gave Flexnerian medicine headaches. The first and apparently more successful (at least in monetary terms) was complementary-alternative medicine. This article is not about that history. The second was EBM.

The basic truth that I have never seen mentioned in a scholarly discussion of EBM and its origins was that it grew out of the primary care medicine movement as a challenge to the authority and power of the Flexnerian establishment. EBM tried to turn “science” on its head. Formerly the fount of all real knowledge, lab bench research was now derided as nearly irrelevant. Unless one knew how the intervention worked in populations of real patients–ideally in their free-range state rather than as they appeared in the corridors of university hospitals–one knew nothing about whether one should or should not administer the intervention. The people who knew best how to design and to interpret these new research studies were not subspecialists, but academic primary care physicians and their co-conspirators, the clinical epidemiologists (who were also tired of being looked down upon and marginalized by their “real science” peers).

The EBM challenge appears to have been a considerable success. EBM enthusiasts appear to greatly outnumber EBM naysayers in the academic medical center. Even subspecialists are now belatedly trying to get onto the EBM bandwagon, and the funding for outcome trials in community settings has increased greatly. As medical schools develop new curriculum in information assessment and management, primary care faculty move into a relatively more central role in the educational process.

EBM’s apparent success has occurred despite two important limitations. First, it is too early to tell whether, and how much, EBM practices will actually improve the outcomes of medical care in various settings (showing that EBM itself is not yet truly evidence-based). Second, there is a good deal of what I consider to be false, or at least crude, EBM roaming about which threatens to give the real article a bad name. Where good EBM says, “Base your clinical decisions on the best available evidence, whatever it might be,” crude EBM says, “Find a randomized clinical trial, put it on a pedestal, and worship it.” EBM may at present be safe from its enemies but we still have to worry about its friends.

The concluding point is simply that defenders of EBM, like their predecessors who defended Flexnerian medicine, would wish to assume that it has achieved its level of authority because it is self-evidently right. In actuality it has achieved its authority and power because of a set of social and cultural conditions that altered the power structure in a way that gave it an opening. Much has now been written about the way that Flexnerian medicine achieved its power and authority in the years following the Flexner Report. I look forward to reading some day the similar history to be written about EBM.