Tuesday, April 6, 2010

Evidence: What the bleep do we really know?

So I know that my blogging has fallen off a bit, and I am sure you are all sorely disappointed (or not). Let me try to explain why.

There are several things going on to nudge me toward the next rung in the evolution of my thinking about healthcare and evidence. The event most responsible for this re-examination of my assumptions is the previously-mentioned illness of a loved one, along with my need to be closely involved with his care decisions. I think that I have generally adequately voiced my frustration with how decisions are made in our healthcare system, and where the switches for these choices should be as opposed to where they are. I am even more convinced now that by the time the physician and the family are considering expensive options with marginal effectiveness, the cat is already out of the bag: how can either the distraught family or the committed healthcare provider not consider those, despite shaky evidence of the value?

But this is not all. I have actually been cogitating the entire way we do evidence and evidence-based medicine. When we invoke evidence, we generally talk about some scientific study's findings, or a group of studies either showing similar or differing results. Let's keep stepping back and looking at the components. The scientific community, based on some statistical and other methodological considerations has come to a consensus around what constitutes valid study designs. This consensus is based on a profound understanding of the tools available to us to answer the questions at hand. The key concept here is that of "available tools". As new tools become available, we introduce them into our research armamentarium to go deeper and further. What we need to appreciate, however, is that "deeper" and "further" are directional words: they imply the same direction as before, only beyond the current stopping point. This is a natural way for us to think, since even our tools are built on the foundation of what has been used previously.

So, what emerges is a picture of being emotionally committed to a certain way of viewing the question, the processes of answering it and the actual answers. And what if by narrowing ourselves to this one particular way of examining the world, to this one particular way to collect and interpret the evidence, we have effectively ignored all other possibilities?

Let me try to clarify what I mean a little further. We spend our days walking through waves. Some of these waves we can detect through our own senses: sound, light, for example. Others we need special external "receptors" to detect, such as radio and micro-waves. Is it possible that there are some other, heretofore unknown waves (or other phenomena) that are around us that we are unable to attune to because of our biology? Is it kooky to think that this is possible, or is it simply blind to walk away from such possibility?

The answer may be that it is both. Nevertheless, it is highly likely that there are many biological phenomena that are not amenable to being examined through our narrow prism of current methodology. We as scientists and clinicians need to be open to this possibility. The Buddha said that both preachers and scholars are blind because they constantly commit themselves to partially-seen truths. Given the shambles in which we find not only our nation's healthcare system, but also the health of its citizens, this would be a great time for this epiphany to penetrate our collective psyche and strive toward a broader view of possibilities. Let's give up the arrogance of ignorance in favor of the humbleness of enlightenment.

And these are my latest thoughts. I am not saying that they are the only way or that they are even remotely correct. But here they are nevertheless. Do with them what you will.            

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