Abstract
During a recent visit to China, I met Dr. Mitchell Levine, MD, PhD, from McMaster University in Canada. We were both invited to present at an event hosted by Beijing University of Chinese Medicine, and we immediately connected once we discovered that Dr. Levine was on the dissertation committee for my good friend and Medical Acupuncture editorial board member Jeremy Ng, who earned his PhD at McMaster.
D. Levine’s presentation was on the birth of evidenced based medicine (EBM) in the Department of Clinical Epidemiology at McMaster University in the late 90’s. Dr. David Sackett’s foundational work in the late 70’s and 80’s led to a local movement that ultimately became a new medical paradigm in the early 2000’s 1 This new paradigm was made possible with the help of the internet and the new ability to search and access scientific literature online. It’s hard to believe that EBM, now adopted globally by all developed nations, is only 25 years old.
Medical students today are taught that EBM is the gold standard. They are taught that clinical scientists collect evidence, research scientists synthesize and analyze the evidence, then teams of expert scientists report the evidence in clinical practice guidelines, and insurance payers and policymakers use the guidelines to determine what they will pay for.
At the beginning of EBM’s expansion in 2004, I was working in a hospital-based pain center with two anesthesiologists specializing in pain medicine. I remember hearing the physicians say they did not like the idea of EBM. They couldn’t visualize a future where insurers and policymakers with no medical training would tell them what they can and cannot do in a clinical setting.
I remember similar resistance from the TCM community. In 2011, during a research symposium I led on EBM with the faculty of Pacific College of Oriental Medicine (Pacific College of Integrative Medicine) in Chicago, the faculty expressed their concerns on how EBM would threaten the art and beauty of how TCM treatments are tailored for each patient’s individual diagnostic pattern and symptoms as opposed to a prescribed set of points for a specific diagnosis reported in a clinical trial.
Today, 25 years after EBM was unleashed, I find myself reflecting on how EBM has helped and hurt medicine and public health in the United States. In my field of pain medicine, EBM helped curb the overuse of spine surgeries, injections, imaging, and narcotic prescriptions that were mostly driven by corporations. EBM helped standardize all medical education, and new research funding became available to collect more evidence, and more jobs were created to conduct the research.
I can also see where the new paradigm did exactly what the anesthesiologists and the TCM faculty feared. I think it hurt the art and beauty of medical diagnosis and clinical decision-making. Twenty-five years ago, physicians had more freedom to try new things in the clinic, and they had less barriers such as time limit for patient encounters and prior authorizations for treatment.
Today multiple clinical practice guidelines have been developed and uploaded into AI tools for multiple levels of clinician providers (MD, NP, PA, RN, EMT) to test, diagnose, and treat their patients quickly and efficiently. I think new tools are good, but too much dependence on the tools is not good.
EBM is the new paradigm; it’s here to stay, but I hope we do not lose the ability to see the beauty in the cells, the organs and the flow of blood and Qi, and the perfect dance of bones, muscles, nerves, and skin. I hope we do not lose the ability to diagnose; to truly connect with our patients so we can uncover the root of the problem that causes the symptoms that brought them to us. I hope we do not lose the art in the different fields of medicine we practice in this new paradigm.