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Qiaochu_Yuan comments on MetaMed: Evidence-Based Healthcare - LessWrong
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It is fairly terrifying that the term "evidence-based medicine" exists because that implies that there are other kinds.
LessWrong is a non-evidence-based method of teaching rationality. We don't have good evidence that someone will get more rational after reading the sequences.
You can make a reasonable theoretic argument that people will get more rational. You don't have the kind of evidence that you need for a EBM-treatment. In most domains where we make choices in our lives you don't follow pratices that are supported by evidence from peer-reviewed trials.
You don't get a haircut from a barber who practices evidence-based barbering. Even the people who pay a lot of money for their haircuts don't. Reading scientific papers just isn't the only way to gather useful knowledge.
The term evidence-based medicine comes from a published in 1992.
It says:
I wouldn't want someone to practice open-heart surgery on me based on his intuition but I don't see a problem with taking a message from someone who read no scientific papers but who let's themselves be guided by his intuition and who has a positive track record with other patients.
Sure, but the idea that one should explicitly go about trying to teach rationality because there are these things called biases is much younger than the idea of medicine. Doctors have had a much longer time than LessWrong to get their act together.
The idea of teaching people to think better isn't new. Aristoteles also tried to teach a form of rationality. But even if the idea would be radically new, why would that matter?
Why should newer ideas be subject to a lower standard of evidence? Fairness? If you want to know the truth fairness has no place.
Let's look at another example: Romantic courtship. Do you practice evidence-based courtship, when you seek a fulfilling relationship with a woman? Would you say there no other form of courtship besides evidence-based courtship?
Most humans don't practice evidence-based courtship. Sometimes courtship doesn't work out. You can blame it on couple not being familiar with the scientific papers that are published on the subject of human courtship.
Nobody has shown that given the couple those scientific papers improves their relationship changes. Nobody has shown with EBM like evidence standards that doctors who are in touch with the scientific literature archieve better health outcomes for their patients.
That doesn't mean to me that EBM has no place, but I don't see a reason to reject any approach to increase my health that isn't backed by EBM.
There's some scientific evidence that suggests that vitamin D is good. In the blogosphere there are people who found that taking vitamin D supplements first thing in the morning is better than taking them in the evening. There's no trial for the timing of vitamin D supplements. I still take them first thing in the morning.
I think there's some sort of rule against discussing PUA here.
Not so much a rule against it as an understanding that it consistently leads to low-quality discussion.
(Which ChristianKI didn't do. His kind of general observation isn't the kind that brings on the notorious failure mode of courtship moralizing.)
That's not exactly 100.00% true -- I once overheard a barber priding himself with the fact that someone once got laid the night after getting a haircut from him.
Jokes aside, barbering is evidence-based -- given that it works at all, then barbers either have knowledge of how to do that hard-coded in their DNA (unlikely) or have learned to do that -- using evidence (even though not in a systematized way). You can immediately see that if you use this cutting technique then your client's hair will look this way. OTOH, a practitioner of non-evidence-based medicine cannot immediately see that giving a patient this substance diluted in 10^20 times as much water or sticking a needle in this particular spot or whatever will help cure the patient. (Likewise, musicians are normally evidence-based musicians to some extent, but astrologists are not evidence-based astrologists; can you find more examples?)
If you interpret evidence-based in the widest sense possible, the phrase sort of loses its meaning. Note that the very post you quote explains the intended contrast between systematic and statistical use of evidence versus intuition and traditional experience based human learning.
Besides, would you not say that astrologers figure out both how to be optimally vague, avoiding being wrong while exciting their readers, much the same way musicians figure out what sounds good?
Yes, but “intuition and traditional experience based human learning” is probably much less reliable in medicine than it is in barbering, so the latter isn't a good example in a discussion about the former.
:-)
Something similar could be said about practitioners of alternative medicine, though.
The goal of barbering is to create haircuts that increase the attractiveness of the client to people besides the barber and the client.
A barber might think: "All my clients look really great", when in reality his haircuts reduce the attractiveness of the clients.
Surely, judging someone's attractiveness using your System 1 alone is less hard than judging someone's health using your System 1 alone, for most people in most situations?
A professional barber is likely to notice a lot of things about a haircut that the average person doesn't see. It could be that he creates haircuts that look impressive to other barbers but don't look good to the average person of the opposing sex who isn't a barber.
I do think that you can get a decent assessment of someone's backpain by asking them whether it has gotten better. Actually that's even how most scientific studies who measure pain do it. They let the person rate their pain subjectively and when the subjective rating gets better through the drug they see it as a win.
For a lot of serious health issues it's easy to see when a person gets better.
Most homeopathists spend more time interviewing their patients and getting a good understanding of their condition than the average mainstream doctor who takes 5 minutes per patient.
I think the barbering example is excellent - it illustrates that, while controlled experiments more or less is physics, and while physics is great, it is probably not going to bring a paradigm shift to barbering any time soon. One should not expect all domains to be equally well suited to a cut and dried scientific approach.
Where medicine lies on this continuum of suitedness is an open question - it is probably even a misleading question, with medicine being a collection of vastly different problems. However, it is not at all obvious that simply turning up the scientificness dial is going to make things better. It is for instance conceivable that there are already people treating medicine as a hard science, and that the current balance of intuition and evidence in medicine reflects how effective these two approaches are.
I am not trying to argue whether astrology is evidence-based or not. I am saying that the very inclusive definition of evidence-based which encompasses barbering is, (a) nearly useless because it includes every possible way of doing medicine and (b) probably not the one intended by the others using the term.
Huh? What evidence are homoeopathy and crystal healing and similar (assuming that's what Qiaochu_Yuan meant by “other kinds”) based on?
EDIT: Apparently not.
There are even dozens of scientific studies that support homeopathy. According to a report titled "Effectiveness, Safety and Cost-Effectiveness of Homeopathy in General Practice – Summarized Health Technology Assessment" commissioned by the Swiss government:
There are plenty people out there who can explain you why all those homeopathy studies are flawed, but on the other hand how many double blind controlled trials do you know that show that barbers can create haircuts that increase someone's chances with the opposing sex?
But in general people do buy homeopathic medicine not because they read the report of the Swiss government and belief it. They buy it based on anecdotal evidence. They hear that some friend had success with homeopathy and then the go out and buy it.
The fact that you are ideologically opposed to homeopathy and crystal healing working, doesn't mean that it fails to produce anecdotal evidence.
<nitpick>If that was the only point of barbers, then already-married people, prepubescent children, homosexuals, etc. would never go to the barber's.</nitpick>
"Other kinds" meant "whatever mainstream medicine does that doesn't fall under the evidence-based label," not alternative medicine. I should've been clearer.
Yes, I realized that later, while reading another branch of the thread (see my edit).
What do you mean with "mainstream medicine" in that context?
What ambiguity is there in what I mean by "mainstream medicine" here?
That's wrong. If a acupuncturist puts needles in 10 people and 5 of them lose their back pain than he has "unsystematic clinical experience" that provides evidence for his treatment.
The core of evidence-based medicine is the belief that you shouldn't use that kind of evidence for clinical decision making but that doctors should read medicial journals that report clinical trials that show whether or not a treatment works.
Actually musicians and astrologists are very similar. Both make money with providing entertaining performances for their clients. Members of those professions who ignore evidence about what entertains their clients go out of business.
Maybe some of those 5 would have lost their pain even without needles. Whereas the barber knows what his client would have looked like without the hair cut.
Right, that's why it's unsystematic.
In the Bayesian sense of the word, "I stuck a needle in this person and the amount of pain he reported went down" would have to be considered to be evidence that would increase the Bayesian possibility that your hypothesis that acupuncture helps back pain is correct. However, it's not systematic, scientific evidence. To get that kind of evidence, you would have to do systematic studies of a large number of people, give some of them acupuncture and give some of them asprin, and see what the statistical result is.
I think that's what bogging this discussion down here, is that the word "evidence" is being used in two different ways. If we were perfectly rational beings, we would be able to use either kind of evidence, but the problem is that the first kind of evidence (individual unsystematic personal experiences) tends to be warped by all kinds of biases (selection bias, especially) making it hard to use in any kind of reliable way. You use it if it's all you have, but systematic evidence is very much preferable.
OK, if you consider the point of astrology to be “making money”, as opposed to “predicting people's personalities and future events”, then it is evidence-based -- but then again, if you consider the point of alternative medicine to be “making money”, as opposed to “improving people's health”, then it is evidence-based as well. (But now that Qiaochu_Yuan has made clear that it's not alternative medicine that he was talking about, this is kind of moot, so I'll tap out now.)
I didn't. I advocated another goal, entertainment. I don't know that much about astrology but I think a fair percentage of the people who do pay a astrologists do it for entertainement purposes.
Letting someone stick needles inside you, when you go to a acupuncturist is less about getting entertainement.
The kind of people who like astrology often also like other personality tests that they find in magazines. People enjoy going through those tests.
If an astrologer would tell people something about their personality that's accurate but that those people aren't willing to accept, I doubt he would stay long in business.
A bit like the musician who only plays music that he himself considers to be good, but that's "too advanced" for his audience. If the musician only sees his own opinion of his work he's not different than an astrologer who only sees whether his horoscope is good. If you call that musician "evidence-based" than the astrologer who goes after his own judgement of his work is also "evidence-based".
Why does that matter to the question whether barbers can be meaningfully to be said to practice evidence-based barbering?
I was claiming that barbering is more evidence-based than alternative medicine, but if alternative medicine is not what's being discussed, then even if I turned out to be right it still wouldn't be relevant.
Only in the sense that the term "pro-life" implies than there exist people opposed to life.
pro-life is an intentional misuse of ontology.
Opposed to all life? No. Opposed to specific, nonsentient life when weighed against the mother's choice? Yes.
A perusal of murder and suicide statistics - even the fact that such statistics exist - suggests the conclusion that there may, in fact, exist some people opposed to life; sometimes their own, sometimes that of others.
That's irrelevant to the point that incogn is making, though, which is that you can't make that inference from the fact that a label called "pro-life" exists because it's rhetoric. I'm willing to believe that the label "evidence-based medicine" is also rhetoric, but I don't actually know that yet; I would first have to know what doctors were doing before EBM became a thing.
And how good the followers of EBM are at actually being evidence based as opposed Straw Vulcan.
On the positive side, evidence-based medicine promotes greater measurement of patient outcomes and sharing of that information to weigh treatment options.
On the negative side, it is largely about denying patients coverage and access to treatments based on officially approved disease models and preference trade offs that ignores evidence that was not used in the model and overrules patient preferences. It's evidence ignoring and patient controlling medicine.
I think you unknowingly {submitted this comment prematurely}? :)
Thanks. I edited around and left that last line when I should have deleted it.
All tidy now.
You mean like acupuncture?
Wikipedia informs me that evidence-based medicine is a movement in the health care community that really only got underways in the 90s. I am not sure I want to know what the health care community was doing before the 90s. I'm not talking about alternative medicine, I'm talking about whatever mainstream medicine was and is doing that doesn't fall under this label.
Well, until the mid-80's doctors believed that infants either a) didn't feel pain or b) wouldn't remember it anyway (mostly because of this study from the 40's), so they didn't use anesthesia for infants when performing heart surgery until someone collected evidence that babies were more likely to live through the surgery if given something to knock them out.
EDIT: Removed extraneous word
Really? I notice (with some relief) that the control babies in the linked study still got anaesthesia; it's just that they got nitrous oxide instead of nitrous oxide and fentanyl.
On the bright side, some of it was just evidence-based medicine without the branding.
For example, the UK Medical Research Council put randomized trials on the map in 1948 with its randomized trial of streptomycin, which had been discovered only a few years before. The massive 1954 trials of the famous Salk polio vaccine also included a randomized trial comprising over 700,000 children. (That said, the non-randomized trial was even larger; the origin of this odd, hybrid study design is an interesting bit of history.)
Quoth said Wikipedia article, in the "criticisms":
"EBM applies to groups of people but this does not preclude clinicians from using their personal experience in deciding how to treat each patient. One author advises that "the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand" and suggests that evidence-based medicine should not discount the value of clinical experience.[26] Another author stated that "the practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research".[1]"
Which suggests that the precursor to EBM is a combination of Education and Intuition. Sorry if I'm not framing it terribly well - there's an intuitive category in my head for this method, but I've never really had to refer to it explicitly. It's the same technique I use to troubleshoot computer problems - I get a hunch as to what is causing it, and then proceed through a mixture of "safe, generalized advice" (try rebooting!) and "advice specific to the problem I think it is" (aha, you must not have your DNS configured correctly). If both of those fail, THEN I'll resort to actually collecting data, analyzing it, and seeing where that leads me - "have you had other problems?", "hmm, let me look up this error code..."
I've generally observed this path as the default human behavior, with "call someone else" occurring when they hit the limit of their abilities.
Not a bad plan if you know the limits of your abilities and aren't trained to act confident even when you're not.
For a lot of the medical advances we had earlier in the 20th century, you didn't really need to do large-scale clinical studies to see if it was working. You gave someone an antibiotic, and they suddenly got much better. You gave people a polio vaccine, and they didn't get polio. You took someone's appendix out, and they didn't die.
It was really later in the 20th century, when medicine got more and more focused on treating and preventing long-term degenerative illnesses like cancer or heart attacks or high blood pressure, that it became more vital to measure the difference in a large-scale statistical way between how effective different types of treatment were over a long period of time.
Not the best examples, although you're right about appendectomies! I nonetheless agree with the broader point that decades ago there was less need for fine-grained, systematic medical studies (you were just unlucky in your choice of examples).
IIRC, acupuncture has some limited use, probably as a combination of placebo and endorfin release. Unless you knew about those, the evidence would suggest you were on to something.