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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-Loviss suggestionthat
we must always remember the distribution of power in social relationsfurther
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 FPs 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 FPs 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 MSUs
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 students
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 patientsideally
in their free-range state rather than as they appeared in the corridors
of university hospitalsone 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.
EBMs 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.
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