Medical Journal of Dr. D.Y. Patil Vidyapeeth

EDITORIAL
Year
: 2022  |  Volume : 15  |  Issue : 5  |  Page : 617--618

Eminence-based medicine vs. evidence-based medicine: All that glitters is not gold


Amitav Banerjee 
 Department of Community Medicine, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India

Correspondence Address:
Amitav Banerjee
Department of Community Medicine, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra
India




How to cite this article:
Banerjee A. Eminence-based medicine vs. evidence-based medicine: All that glitters is not gold.Med J DY Patil Vidyapeeth 2022;15:617-618


How to cite this URL:
Banerjee A. Eminence-based medicine vs. evidence-based medicine: All that glitters is not gold. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Dec 6 ];15:617-618
Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/617/357775


Full Text



In the present environment of high-pressure promotion of their products by the pharmaceutical industry, skills in appraising the evidence in published and promotional literature assume greater importance than ever. There are efforts in place to equip prospective health care professionals with the basic insights needed to critically evaluate published literature. However, these consist of cursory 3 to 7 days mandatory research methodology workshops, mostly to help the postgraduate student kick-start their dissertation work. After completion of the thesis or at the most publishing a couple of papers, often mandatory rather than due to a burning desire to contribute to the medical literature, the critical appraisal skills required for practicing evidence based medicine are not exercised by most professionals.

Once in practice, they are extremely busy to spare time to refresh these skills. Moreover, more often than not, the research methodology courses they undertake during their training are compressed and too dense for the uninitiated to comprehend. They only familiarize the participants with a handful of jargons and provide a certificate which is required for appearing in the qualifying university examination. The jargons come in handy when the lucky and chosen few give television interviews in their future lucrative careers. Phrases like “trust the science,” “evidence-based-medicine,” “peer reviewed trials,” “relative risk reduction,” “statistically significant,” and so on add a coat of scientific veneer and glitter sufficient to make an impact on professionals and the public alike. Most often, neither the experts nor their target audiences truly understand the nuances of these terms, but like religious mantras they have to be uttered to gain credibility. The boundaries between ancient religion and modern science are becoming blurred.

The not-so-invisible hand of the pharmaceutical industry plays a major role in this scenario. Developing a new product is a long and an extremely costly venture, and for survival of the manufacturers their products have to sell and sell well. Accomplished doctors highly competent in their respective super-specialties may, over the years, become very eminent, almost acquiring celebrity status. However, most may lack the skill as well as the time to critically appraise the published literature needed for practicing evidence-based medicine. These celebrity doctors, often unwittingly, become ideal spokespersons for the pharmaceutical industry.

An example of how the glitter of eminence-based medicine scores over the gold standard of evidence-based medicine will illustrate the free-fall of the medical profession we are witnessing.

A paper[1] was published in the prestigious Journal of American Medical Academy (JAMA) in 2002 reporting the results of an almost decade-old study painstakingly carried out to ascertain the efficacy of expanded use of statins recommended in the 2001 cholesterol guidelines.[2] This study enrolled more than 10,000 patients at high risk of developing coronary heart disease of both genders over 55 years of age who would have qualified for statin therapy according to the new guidelines. The participants were randomly assigned to the statin (Pravachol) group and the control group who received the usual care from their personal physicians. By the end of the study, 83% of the statin group were still taking the statin and 26% of the control group had been prescribed statins by their personal physicians, a perfect situation to allow for ascertainment how many cardiac events could be prevented by tripling the number of people on statins. Coincidently, the new guidelines had recommended tripling the number of people on statins to benefit a larger patient pool. Based on the findings, the study concluded that increasing the number of people receiving statins three times neither prevented heart disease nor decreased the overall risk of death. There was no advantage of prescribing statins beyond the earlier norms. It also did not benefit people beyond 55 years in either gender, with or without diabetes, or with or without heart disease or those with higher or lower cholesterol than 130 mg/dL.[1],[3]

When evidence is unpalatable, eminence comes to the rescue. The study findings were roundly criticized by experts in medical journals on the grounds that in the control group, too few patients were put on statins by their physicians which effaced the effect size, ignoring that the main research question of the study was exactly that. High-risk patients put on statins by their doctors were the ones who derived the maximum benefit; tripling the number by including other patients did not provide any further benefit.

An editorial accompanied the publication of the controversial study in JAMA. This was written by an eminent cardiologist.[4] It stated, “Physicians might be tempted to conclude that this large study demonstrates that statins do not work; however it is well known that they do.” So much for evidence-based medicine!

The author of this editorial was one of the original 14 authors of the 2001 cholesterol guidelines. He also declared financial conflicts of interest with nine drug companies in the disclosures accompanying the editorial in JAMA. But few read the fine print. The glitter of eminence has spawned a great number of what we call “celebrity doctors” who act as spokespersons of the industry rather than of science and evidence-based medicine.

References

1ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs usual care: The antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT-LLT). JAMA 2002;288:2998-3007.
2National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143-421.
3Abramson J. Overdosed America-The Broken Promise of American Medicine. New York: Harper Perennial; 2005.
4Pasternak RC. The ALLHAT lipid lowering trial--less is less. JAMA 2002;288:3042-4.