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Evidence Based Medicine, or evidences to distort Medicine

Before I begin, I must express my sincere adhesion to Scientific Medicine or Evidence Based Medicine (EBM). In addition, I must say that I profess a kind of devotion for it. For it is what I believe and what I practice everyday.

Nevertheless, I have the impression that something about it has gone awry in twenty-five years of medical profession. Something smelled bad. And I wanted to know if somebody else shared my perception.

Twenty years ago, my starting point was – and still is – top rank medical journals like The Lancet or The New England Journal of Medicine. With them – as well as with others – I tried to create a critical conscience. Those articles were linked to a series of well-known professors from whom I wanted to take an example for my own career.

Next generation of investigators developed their scientific careers with articles often linked to the emergence of new drugs. Below the presenting page of these papers, you could often read the name of the sponsoring pharmaceutical company in tiny letters. These papers, often phase III clinical trials, either tried to widen the field for the drug use in different settings, or to prove its superiority versus new comparators. In that time, these trials reached second-rank journals, having a lesser impact index than the previously mentioned ones.

Shortly after the publication of the formers, these investigators were recruited in a wide international tour in order to spread the beneficial effects of the new molecules. They attained a preeminent position in symposia, where you usually found a common finding: below the title of the presentation and the name of the speaker, you could read the name of the sponsoring pharmaceutical company, in tiny words.

But time went by. Old editors-in-chief of The New England Journal of Medicine did resigned because of discrepancies with the “government” of the Journal. Some years after, one of them, prof. Marcia Angell, did publish a controversial essay whose name was “The Truth about the Drug Companies: How They Deceive us and What to Do about it”. Some time later, we found that phase III clinical trials previously found in second-rank journals began to appear in The Lancet and The New England Journal of Medicine. Some of us began to wonder if the above-mentioned resignations could have a relationship with this fact.

But more time went by. Institutions began to worry about drug expenses. Doctors began to be controlled and submitted to pressure. Our practice had to agree to international guidelines. These Clinical Practice Guidelines, passed by a board of the most prestigious International Scientific Societies, were something unavoidable or almost compulsory. And, on the presenting page of the guidelines, here they were, once again. You could see the names of the well-known professors. You could recognize those who had signed the scientific papers. You remembered those articles for which the sponsoring pharmaceutical company was reminded below, in little letters. Now the professors and the investigators were signing universal recommendations based upon the articles they had written few years ago, for which they had generously been paid, as well as for their prestige, credibility and sales promotion. The Pharmaceuticals had paid for them to occupy a preeminent position in every symposium in the world. And the Pharmaceuticals did sustain Scientific Societies whose official journals would embrace with a benevolent eye a paper that was to benefit from the journal impact and prestige.

It is medical science conceived like an inexhaustible business, and the investigator like a great scale salesman (K.O.L. Key Opinion Leader). And perhaps it is trickier. Because they don’t sell lies – scientific papers aren’t not that, anyway -, but half true instead – findings of their own sellers, often devoid of a full critical analysis -. To end, I must put forward that I still consider EBM to be true and the truth. It’s the best that we have, maybe the only one to trust. But it is conceivable that we have allowed an expensive, selfish drift of it, possibly because of professional laziness and comfort.


@frelimpio

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