EBM. Do you know what it really means?

Right now, in this time of COVID-19, there’s a lot of unknowns. There are known unknowns and unknown unknowns, to borrow a phrase from Donald Rumsfeld. Right now, many of those unknowns, both known and unknown, apply to the treatment and management of the disease.  Less than two weeks ago, very educated and skilled clinicians were treating COVID-19 patients like Acute Respiratory Distress Syndrome (ARDS) and intubating patients early and placing them on a ventilator — often with terrible results for the patient  as well as overwhelming the critical care system. As we have increased our understanding of the disease, we’re finding it’s less a ventilation issue and much more an oxygenation issue with a breakdown of iron in the bloodstream.  We’ve gone from intubating patients to laying patients prone with high flow oxygen — not to mention seeing better results.

And like with any emerging issue in medicine, especially when there’s a dearth of known treatments, physicians will try novel treatments, including the off-label use of medications already in use. One of those is hydroxychloroquine, sometimes administered in conjunction with azithromycin. There have been some reports of success of treating COVID-19 patients with this combination, enough so that the President has become a loud cheerleader for this combination.  Whether you adulate, like, dislike, or loathe the current President, no one can deny that he’s a master showman who understands the power of the bully pulpit that being the occupant of the Oval Office gives you.

And because the treatment is being advocated by one of America’s most polarizing politicians, there’s immediate opposition to the combination of hydroxychloroquine and azithromycin.  If you’ve been around any EMS (or even any medical) discussions on social media, especially Twitter, politics routinely injects itself into medicine. There are a lot of physicians and clinicians of all types who feel a joint obligation to both medicine and being “woke.”

Right now, the woke clinicians on social media are opposing this particular treatment regimen in the name of “evidence based medicine,” believing that the double-blind study is the only acceptable evidence of the efficacy of a treatment or medication.  (I’d note that many of these people who poke fun at religion have a similarly blind faith in “science.”)

Yes, the double-blind study is the sine qua non of scientific evidence. I’d like a double-blind study to confirm everything that I do in medicine. But that can be taken to an extreme.  See also the satirical double-blind study of parachutes.

For everyone who blindly opposes new medical interventions based on their own scientific education obtained from the Twitter Institute of Advanced Studies and sharing Neal DeGrasse Tyson memes that repeat the phrase “science,” I’d submit that you don’t know where and how the phrase “evidence based medicine”comes from.  While evidence based medicine, also known as EBM, arose in the medical field for use by clinicians, it rapidly became the watchword of the managed care industry.  In 1985, Blue Cross/Blue Shield began using EBM to evaluate new treatment regimens. In 1991, Kaiser Permanente began using EBM guidelines for treatments.  In other words, the previously science-oriented concept of EBM became a cost control mechanism by implemented by managed care.

In other words, the people pushing the EBM mantra lack the understanding of what EBM is and how it differs from the scientific method.  In science, we should absolutely be pushing for the scientific method.  In an ideal world, we’d have the time, resources, and ability to do randomized double-blind studies on everything we do in medicine.  But we don’t.  And when humans are suffering, maybe sometimes we need to consider ethics in conjunction with a blind devotion to EBM or the scientific method.

Of course, the study of ethics is rarely absolute. It’s full of nuance and variations. And as I’ve discussed before, that’s something that neither EMS nor much of social media excel at. It’s almost like those “core courses” in humanities and social sciences might be a bit more relevant than the Twitter Science Brigade believes.  Neither medicine nor science should have an agenda.  But precisely because social media and the 24 hour news cycle exist, the very term “science” has taken on a political bent.  (e.g. “Science is real.”)

On a final note, while medicine is based in science, I consider medicine an applied science, much like engineering.  Medicine isn’t a pure science.  Rather, it’s the application of science and knowledge to practical problems.  It’s time that we all remember that — and that an education involves much more than science alone.  And science is more than sharing links from Twitter. Science is but one part of a well-rounded education, something which most of the medical world seems to have forgotten.

And that devotion to absolutism in the name of EBM or science is but another symptom of the divided red versus blue world that we’re currently in. Sadly, even a disease like COVID-19 has done little more than highlight the deep divisions in our country.

Thanks for reading.  And we will get through this — just as we got through the Great Depression, World War II, and 9/11.  On that note, “Let’s roll.”