We hear stories about how the body works to justify treatments effects, yet how often do these treatments actually pan out? We hear doctors disagree and how should we—as learners—make sense of those disputes? In this episode, OBGYN Dr. Howard Herrell explore these topics and more. Dr. Herrell has been an incredible mentor for improving my critical appraisal and has been generous with his time and energy in answering my questions through email and other chats.
I hope you enjoy the episode and it sparks some enthusiasm for an eye-roll-inducing topic: evidence based medicine
[0:00] Introduction
[1:30] Herrell’s view of the role of science in medicine
[3:30] The characteristic methodologies that distinguish allopathic medicine from alternative models of medicine
[6:30] The Skeptical empiricist approach to biological plausibility as it relates to justifying efficacy in medicine
[10:00] Interventionist bias and skeptical empiricism and how a long list of medical reversals makes arguing for efficacy from biological plausibility unreliable
Trials discussed (because we are THAT extra)
- anti-arrhythmics post-MI do not improve all cause mortality (CAST trial)
- PCI for stable angina does not improve all cause mortality (COURAGE trial)
- Halsted procedure radical mastectomy did not improve breast cancer outcomes (NSABP B-04)
- Surgical treatment of knee osteoarthritis did not outperform sham surgery (Moseley et al. 2002)
- Surgical denervation for treating renal hypertension did not outperform sham surgery at 6 months between renal denervation group and sham control group (SYMPLICITY HTN-3 trial)
[17:15] Clarifying the role of hypothetical mechanisms in medicine
[19:30] The story of DES and how it shows the fallibility of biological mechanistic reasoning w/o empirical trials
[22:00] Inertia in clinical practice and it’s detrimental effects and why some evidence in medicine needs an expiration date
[28:00] Methodological pluralism as it relates to evidence based medicine
- OBGYN evidentiary disputes
- parachute arguments
- the relationship between smoking and lung cancer
- the relationship between LDL and heart disease
[36:50] Making sense of disputes between clinicians (Standards vs Fashion vs Context vs Psychological Propensities (thresholds for action/inaction, risk tolerance, etc) vs human values
1. Is this a dispute d/t different evidentiary standards (one person doesn’t need population level data to feel justified in making a certain clinical claim while another does)
2. Is this a dispute d/t therapeutic fashion (this is just what we do)
3. Is this a dispute d/t differences in contextualization (we are treating different patient populations or in different practice contexts or use the same words in different ways because we are in different specialities w/o realizing it and we are both justified and just talking past each other)
[53:00] Where Herrell sits on the utility of debunking alternative medicine and pseudoscience claims in medicine
[59:00] The value of teaching the grey areas of medicine to students
[1:09:00] Cultivating a learning environment that fosters academic inquiry
