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The Dominant Science of Medical Education? :

November 29, 2016

Any guesses on what this author was referring to? Well, if you're paying attention to my blog topics, you know the answer is evidence-based medicine. But is this claim a bit of a stretch? Read on.

Any guesses on what this author was referring to? Well, if you're paying attention to my blog topics, you know the answer is evidence-based medicine. But is this claim a bit of a stretch? Read on.

Hanemaayer A. Evidence-based medicine: a genealogy of the dominant science of medical education. J Med Humanit 2016; 37:449-473. doi 10.1007/s10912-016-9398-0.

I'm using my "5th Tuesday" blog to free myself of the shackles of reviewing articles from AAP Grand Rounds to look a little farther afield, and this article certainly fits the bill. I don't read that many articles from the social sciences, and it takes a bit of adjustment to pick out the salient points of this 25-page discussion.

Obviously I'm a proponent of evidence-based medicine, or I wouldn't be struggling with this blog the past 6+ years. However, this article made me reminisce about my early days of exploring EBM. In particular, I recall attending an international Cochrane Community Colloquium in Baltimore in 1998. This was a few years after EBM became a "thing" and the Cochrane Centre at Oxford was established (both in 1992), the latter growing out of Archibald Cochrane's work on systematic reviews of perinatal research. I was, by 1998, pretty enthused about the new science of EBM, but I recall the Baltimore meeting was a bit of a rude awakening for me. It seemed overwhelmingly populated with another life-form, a group of people who looked normal but seemed to be repeating EBM mantras ceaselessly. (Literature and movie buffs, think 1984, Invasion of the Body Snatchers, or The Stepford Wives.)

In this article, Hanemaayer intended to chronicle the growth of EBM and cement its place in medicine and medical education, particularly with regard to her home institution, McMaster University. She mostly succeeds, though perhaps I was swayed by her managing to name-drop Friedrich Nietzsche and not make it seem like too much of a stretch to relate his writings to EBM (in a good way). In addition to her historical timeline of EBM, I liked her breakdown of EBM into 6 problems that formed the genesis of EBM.

First was what she termed "the laboratory and the clinic." Stated perhaps too simply, what I think she describes is the leap from medicine as a hard science of laboratory experimentation leading to the truth, to an understanding of how medical science should be applied in a practical sense to individual and population healthcare. It's about the unpredictability and variability of biologic science.

This led naturally to the problem of medical authority. In the twentieth century and earlier, experienced clinicians expected that 1 treatment is the answer for any patient with a particular illness. That falls apart when the experts don't agree on the treatment of choice, leading to much variation in clinical practice with uncertain results.

Charging to the rescue is her third problem, that of "new measurements," by which she means the actualization of randomized controlled trials as well as the use of Bayesian logic to guide application of scientific results. For those most interested in the mathematical and even philosophical underpinnings of EBM, Bayes' theorem is the starting place.

Medical education reform, her 4th problem, is still in flux. From my personal vantage point, I think medical schools, at least in the United States, have a long way to go before EBM is used in a practical manner in today's medical practice. This concept ties into her last 2 problems of justifying the new science of clinical epidemiology and linking clinical practice to patient (and population) outcomes.

Hanemaayer's article is mostly of interest to EBM and medical education historians; for me it was a nice summary of how we got to where we are today in EBM.

Thinking back to my time at that Baltimore convention 18 years ago, I was anxious for the meeting to end before those pod people took over my body. Given where I am today, I'm thinking maybe I didn't leave soon enough!

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