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The World of Zero Risk

Everyone knows how important safety and quality assurance is in health care delivery.  I find thinking and talking about this stuff as boring as batshit, even though their objectives are obviously worthwhile.  Most of the "thinking" in the area seems to revolve around approaching the health care service as a system and examining its component parts like a car engine.  Zzzzzzzzzzzzzzzzzzzzzz..............  This, with EBM its close ally, can hopefully lead to some sort of uniform response being recommended for a particular situation.  Also, you should always be very careful.

The endeavours are indeed worthwhile and have done enormous good for patient care over the years.  But could they be done better?  Sometimes I've found their actual products, the protocols and clinical pathways unhelpful or even stupid.  Too vague or too restrictive to apply to the particular case in front of you, or trivially obvious in their focus.  

This French dude was interviewed on ABC radio and this is the first time I've heard anything on the topic which sounded mindful of the realities of clinical care as well as not making me want to remove my ears and place them in a saucer of acid after a minute's listening.  Maybe go the transcript, his accent's pretty strong.

I've thought before that the chiding we often receive for health care being "decades behind aviation" in QA etc to be vacuous, and the part where he basically describes pilots as slow learners who don't cope when the shit goes down is awesome.

Some key points he makes are that protocols can be good or they can be dangerous, that medicine is naturally attuned to dealing with the "unexpected" which is partly why our management of routine tasks is often poor and that innovations in medicine have faster turnover than in wussy jobs like aviation, making uniform approaches to safety less useful.

Swan's interviewing is f*cking hopeless, he strives to box the dude into the established orthodoxy of protocol worship, the dude announces he's going to describe 3 "gold strategies" for their use and Swan just has to interrupt him after 2 with his brainless nattering.  When he got to the Great Medication Error Catastrophe of the Modern Era I prayed that the dude would administer his microphone in the French way (did you know that medication errors cause over 60% of all deaths in developing countries and that without them average life expectancy would be 115 years blah blah blah blah blah blah blah blah?).

So I'll have a look at dude's work myself and get back to you.

"Evidence-based medicine" is a social and not a scientific movement

EBM has few features of a scientific endeavour.  It does not involve generating or testing hypotheses although the research which its proponents seek to influence does.  It authoritatively advocates very specific processes for conducting and interpreting research, embodied in its hierarchy of research design.

The reason this movement has gained prominence and authority within and beyond medicine since 1992 is the support it naturally receives from bureaucracies involved in the delivery of health care.  It provides definitive and comprehensible information free from expert obfuscation and fence-sitting, and a means by which a bureaucracy can use medical research to support desired policy and decisions.  This is true of US pharmaceutical corporations which are able to drive favourable execution and analysis of studies in support of the benefit of drugs they have developed while maintaining a mantle of scientific authority as derived from EBM methods.  It is also true of government bureaucracies in Australia, Britain and other countries where cost containment and the appearance of diligent health care delivery are high priorities.

It is appropriate that these bureaucracies adopt convenient and powerful means to achieve their ends; it is not their responsibility to decide whether EBM actually improves the standard of medical research or practice.

It should also be noted that most medical research which is currently conducted and disseminated with an EBM imprimatur remains high quality science of high value to patients; the pedigrees of the inner workings of these projects are the established disciplines of statistics, epidemiology and what was once simply called scientific research.  EBM as a brand carries intellectual authority beyond the value of its constituent techniques.  There is no reason for the term "evidence-based medicine" to be used nor for the movement to describe itself with these words.  All the underlying philosophy and methods were adopted and promoted before the movement began and all would continue if "EBM" ceased to exist.  Medicine is not medicine if it is not evidence-based.


The socially authoritative nature of the movement has tangible negative effects on day-to-day medical practice and education. Clinicians are offered the quick and easy charms of pre-digested and generalised yet respectable recipes for diagnosis and management which are less beneficial to individual patients than the historically established hypothetico-deductive and skeptical approach to clinical reasoning.  Research design is distorted by EBM imperatives regardless of their relevance to the question at hand.  Medical schools are vulnerable to the appeal of a framework which is more easily summed up and inserted into curricula than the unglamorous and bothersome grind of experiential learning through direct patient contact.