Part I here
Part II here
In part I of this series we answered the basic question, what is evidence based medicine (EBM) with the definition: EBM is the equal use of clinical experience and external evidence to make the best decisions about the care of patients.
In part II we saw how this definition is often discarded for the much more stringent and less useful definition of EBM as the selection of therapies according to the evidence presented in the scientific literature. This evidence is ranked with double blind, placebo controlled studies at the top (considered most authoritative) and clinical experience at the bottom (considered least reliable).
In part III, my intention is to outline how I use EBM in my practice. Alternative or natural practitioners are often dismissed by conventional practitioners with the refrain “not enough evidence” or “hasn’t been proven to work”. This is true only under the strict definition of EBM we talked about in part II but as I will show I base my practice on a great deal of evidence, much of which is not given significant value by the conventional community.
In my practice of medicine, I break evidence down into four quadrants.
Quadrant I – Tradition
The use of food and plants as medicines dates back to the beginnings of humanity and is found in every culture around the globe. The most widely known traditional medical systems are Chinese medicine and Indian (Ayurvedic) medicine which have experience spanning several thousand years, and many generations of healers.
There is a tendency in modern culture to view our predecessors as ignorant or at the very least to think, “they were doing the best they could, but we’re clearly so much smarter and better than they are, after all we have iPods and electricity…” and to discount their knowledge and wisdom. I think this is an arrogant and prideful view. Our ancestors faced many of the same health problems we face today and generations of experience helped them to accumulate a wealth of wisdom about what heals and what doesn’t.
This is not to say that tradition has all of the answers, it doesn’t. Superstition pervades this quadrant, some of the therapies our ancestors used were ineffective and some were downright harmful, and the conditions of our modern lives are uniquely different from those of our ancestors. But to throw out this quadrant of evidence because of these flaws is to “throw the baby out with the bathwater.” We have much to learn from our ancestors, and in my opinion, evidence based medicine starts here. I look at how my Naturopathic predecessors treated disease and restored health, and how traditional cultures around the world used food, plants and other medicines. To this base I add…
Quadrant II – Scientific literature
Because I am a Naturopathic doctor (ND) and not a medical doctor (MD) I have been called anti-science. Let me be clear, I am NOT anti-science. I value and use science, but I also do not revere science. For me it is one of four quadrants of evidence, not the only quadrant.
Science is incredibly valuable. At its best it helps us to uncover mechanisms of action so we can more deeply understand how diseases and medicines work, and how to better use our medicines. It also helps us strip superstition and bias out of tradition and our own personal experiences. But science is also a human endeavor and not something passed on down from ‘on high’. Recent exposés have shown the bad side of science, manipulated for monetary gain: some scientific studies are ghost written by marketing people looking to influence the prescribing habits of doctors, some pharmaceutical companies hold back scientific data that would make their drug look worse, and that studies are manipulated from the very beginning to give the results that are being looked for.
Scientific studies are not gospel, and in my opinion, need to be taken in the context of other quadrants of information. So to them we add…
Quadrant III – Personal clinical experience
Nothing can replace a doctor’s experience with their patients and their medicine, which is why we all value a doctor with years of experience. A doctor’s experience working with their therapies, seeing what works and what doesn’t on real people in front of them, gives personal knowledge of that therapy that cannot be learned from tradition or the scientific literature.
This is not to say we should rely only on clinical experience because we are all subject to our biases and the biases of our patients and the population that we serve. But by placing it in the context of the other quadrants we gain irreplaceable knowledge. The last quadrant is…
Quadrant IV – Non-rational or intuitive
This is the hardest category to explain, and as such is often just ignored and swept under the rug. Medicine is not just a science, it is also an art. Hunches, gut feelings and intuitive leaps of thought play a vital part in the practice of medicine, even for the staunchest scientific practitioners. Sometimes we choose therapies because it simply feels right.
Each of the four quadrants provides valuable evidence that I feel is, in and of itself, insufficient for the practice of EBM. Conventional medicine, I believe, makes the mistake of discarding quadrant I (tradition) and IV (intuition), minimizing quadrant III (clinical experience), and attempting to rely almost exclusively on quadrant II (scientific literature). Alternative medicine, I believe, also makes the same mistakes by rejecting quadrant II (scientific literature) attempting to rely almost exclusively on quadrant I (tradition) and III (clinical experience), while some alternative practitioners think quadrant IV (intuition) by itself is enough.
I value each quadrant equally, and do not rely on any one to provide all the evidence for my treatments. The strongest evidence is where each quadrant converges with the others; where a traditional use is verified by modern scientific studies, the clinical experience of the doctor and their peers, and by the practitioners and patients non-logical intuition. This I believe is truly comprehensive, holistic EBM and best serves patients.
What are your thoughts? We’d love to hear them, please post your comments below.