Since its fairly new term with some serious potential for misunderstanding, I thought I’d take some time to explain what ‘evidence’ actually means with regard to medicine and health sciences. This is a long post with some fairly technical terms. I apologise. But, in the words of Neil deGrasse Tyson ‘“Science literacy is a vaccine against the charlatans of the world that would exploit your ignorance.” And a little understanding of what to look for can make a really big difference with regard to choosing the best health care for your, or your loved ones, situation.
‘Evidence Based’
This is actually a fairly new term, confusing for many people because they have presumed that mainstream medicine has always been ‘evidence based’, when actually up until perhaps 20 years ago, there was no such thing, and its still a long, long way from being standard medical practice. In fact, the AVERAGE gap between “standard’ and ‘best’ medical practice is – wait for it – 17 YEARS.
There are numerous issues around utilising and balancing these aspects, and issues of course with collecting information as well. Some things are difficult to test, or inappropriate. Some things are unethical. Sometimes there are too many complicating factors. And some times it takes a long time to see the results.
In medical practice, evidence is a balance of three main components
- Best external evidence (eg. systematic reviews, randomised controlled trials but also research that measures qualitative patient outcomes)
- Individual clinical expertise (eg. the individual experience and training of the practitioner)
- Patient values and expectations (eg. what the patient will and won’t do, or can and can’t do)
You can see how these three connect in this diagram here, and, as you can see, no single aspect is automatically more valuable than another. It may also be in some circumstances, such as rare or complex conditions, that relying only on external evidence such as clinical trials may result in very limited options (i.e., none) in practice.
Whats an RCT?
You are likely familiar with the term ‘randomised controlled trial’ (RCT) since its one of the more frequently used terms. In fact I find people often turn up in clinic using this term with no idea what it actually means. Like ‘placebo’ (which you’ll hear more about later)
The first thing you should know is that’s it’s a system used and appropriate for testing pharmaceutical drugs. Herbal medicines also perform well under this system. This is, quite simply, because these are substances and can be ‘blinded’, which means given to you without you, or the clinician (or whoever) being able to figure out what they are until afterwards.
Anyone who uses the term ‘RCT’ in regard to a modality other than this is letting you know they have no idea what they are talking about 🙂
Its impossible to ‘blind’ a trained practitioner, and often difficult to blind patients with hands on modalities. With regard to any practitioner modality – acupuncture, surgery, physical therapy, psychotherapy, massage, etc – the method is to use a sham therapy, which is to say something that looks like the real therapy, but isn’t, and then have it assessed by a separate specialist professional who doesn’t know which one the patient received.
As you can imagine, this is difficult – patients often guess which was ‘real’ treatment and which wasn’t (and drop out from the trial, which messes up the results) and it also means that really these studies are comparing one treatment with another treatment which is non specific but still does something. Complicated, yes? Its difficult to prove that a trained psychotherapist having a therapeutic conversation with you gets different results to therapeutic conversation in any other context, or a good chat with your friend. Or that physical therapy from a physiotherapist is any different from going to the gym yourself and moving weights around, or going to session with your fitness trainer. And actually neither of the practitioners above have been able to prove any different results in treatment outcomes in this above scenario. Is there a difference? Of course! But its very hard to prove it. And – they shouldn’t have to. The difference between a trained and untrained practitioner are really pretty obvious 🙂
The issue with where this comes in with Acupuncture is that touch sets off many hormones and that this is involuntary – and still gets some kind of ‘result’ for anything being measured. And in fact, none of the devices used for blinding in Acupuncture studies have been evaluated as effective (see here) – and this was acknowledged by the people who created (and sell) the devices!
An additional issue for Acupuncture studies is properly trained practitioners performing Acupuncture clinical studies, as opposed to practitioners in other modalities doing short courses, not getting results, and these being added to the database for acupuncture efficiency. Believe me this is a significant issue with many Acupuncture clinical studies and of course a long way from a reasonable way to judge a modality!
Bias, ignorance or convenience?
One of the more common presumptions I (and most other ‘alternative’* medical practitioners) often encounter is the idea that because our practice is something less commonly prescribed or recommended, it must have less evidence or proof to demonstrate its usage. This idea is far from being an accurate reflection of reality.Acupuncture actually has the broadest evidence base of the practitioner based modalities and is one of the most proven, effective, safe treatments for numerous conditions.
I’ve discussed this idea in regard to cognitive bias before and its something we as humans are predisposed to – familiar = good, different = bad, and it comes through pretty profoundly at times in regard to our choices with regard to health and treatment options.
The issue is – and I say this with full respect – that many mainstream practices are far from being evidence based. The fact that you’ve heard of it or that is the likely go –to for your local GP may well have more to do with their education, politics, interests, training or simple convenience than with an ‘evidence based’ approach.
If you are unaware of this issue in Western (I call this mainstream) medicine, then you should have a look at these sources Four corners: Wasted and this ABC: Catalyst and now consider this recent (2013) review from the British Medical Journal showing the percentages of evidence for standard medical practice. There are many standard practices happening in mainstream medicine currently which have been shown to be inefficient, and are still occurring at a high rate. At significant cost to the tax payer.
What do you really want to know?
I know personally – and I’ll venture the majority of other patients – are most interested in being able to choose which modality is their best bet for which problem and what the risks and timeframes involved are, rather than comparison to something which provides no useful clinical framework for the best practice.
What we actually want to know is which treatment or modality is the best bet to get results. Both patients and practitioners have right to this information and to make informed decisions accordingly.
Where we have evidence of one better than another it should be recommended and utilised. Where we don’t have that information surely it should be a case of best outcome, least risk as the initial starting block. Individual patient circumstances need to considered. And of course, we all know of certain practitioners sought after either generally or for certain conditions for reasons such as excellent patient care and clinical experience, despite access to precisely the same external evidence.
To acknowledge only the external evidence as valuable does neither patients nor practitioners – of any medical modality – any favours.
Research studies are not the whole (or the only) picture and sometimes treatments with less than perfect evidence need to be considered, because there is simply nothing else left to try. Chinese Medicine and Acupuncture are often useful in this scenario, and its one of the more common phenomena I see in my own practice. I’ve honestly lost track at this stage of the number of people who’ve had blood, scans, specialist appointments galore who have been successfully treated by Chinese Medicine. And – lets be realistic here – there are also people who I have been unable to help.
All reference to Acupuncture and Chinese Medicine refers to Real Acupuncture and Chinese Medicine, the kind practiced by a trained professional, licensed and registered through AHPRA (the Allied Health Professional Regulation Agency). A short weekend course of Dry needling is not the same thing and completely insufficient to gather any kind of (positive) result. I’ve written more detail about it here for your information and understanding. To be sure if your practitioner is registered check here.
Please read this post with the intention in which it was written. I have no interest in ego or turf wars, and this post is intended as an honest discussion around some of the issues encountered in modern clinical practice and how both practitioners and patients can best get results in real world scenarios.
• Just letting you know – I detest this term. The use of the term ‘alternative’ is actually in reference to some medical practices, such as Ayurveda and Chinese Medicine, being complete,independent, holistic, unique medical frameworks for understanding the body and its pathomechanisms for disease and/or healing completely exclusive to any others, instead of modalities which fit within another medical framework, but are unable to exist as separate practices. Chinese Medicine and Ayurveda are two such complete, alternative paradigms for understanding the body and health – hence the use of the word ‘alternative’. Unfortunately, like many such terms, its now used in a different – and incorrect – context.
