Which one do you think is stronger evidence of an analgesic effect of acupuncture? My dancing grandmother with arthritis after acupuncture treatment or scientific explanation?
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| https://www.theveterinarynurse.com/review/article/the-physiological-mechanisms-of-acupuncture-analgesia-and-its-applications-within-veterinary-practice |
Take home lesson: Scientific rationale and good evidence are two different things!
Evidence-based medicine (EBM) is an approach to clinical decision-making that emphasizes the use of the best available evidence from research to inform medical practice. The father of EBM, Dr.Sachett suggested five types of evidence. Sackett's levels of evidence provide a framework for categorizing different types of research based on their quality and reliability of evidence, with randomized controlled trials (RCTs) being the most highly regarded form of evidence in EBM.
Canadian Task Force on the Periodic Health Examination’s Levels of Evidence 1)
| Level | Type of Evidence |
|---|---|
| I | At least 1 RCT with proper randomization |
| II.1 | Well-designed cohort or case-control study |
| II.2 | Time series comparisons or dramatic results from uncontrolled studies |
| III | Expert opinions |
*Adapted from Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979;121:1193-254
It is important to note that Sackett did not consider animal studies and laboratory studies as evidence in his hierarchy. Instead, all of his types of evidence are based on clinical evidence, which involves the observation of patients in clinical settings. This means that Sackett placed a strong emphasis on the use of clinical trials and observational studies, such as cohort and case-control studies, as the primary sources of evidence.While animal studies and laboratory studies can provide important insights into the mechanisms of disease and the effects of treatments, Sackett believed that they were not as relevant to clinical decision-making as clinical evidence. This is because the results of animal and laboratory studies may not always be directly applicable to human patients, and they may not take into account the complex interactions between different biological, psychological, and social factors that can affect human health. In terms of EBM, Yes, my dancing grandmother is better evidence than scientific rationale, even if you cannot explain why
Later, some scholars, probably bench researchers who is still living in modernism era, started to include animal studies and laboratory studies as the lowest form of evidence. Bottom line is, in realm of EBM, one patient's experience is more important, even that is subjective, than the result obtained in laboratory bench, even that is objective and filled with scientific jargons.
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| The pyramid of evidence (SUNY Downstate Medical Center, 2004). |
According to Sackett et.al., EBM involves "integrating individual clinical expertise with the best available external clinical evidence from systematic research." This means that EBM practitioners rely heavily on clinical trials and other forms of research to make decisions about patient care. For this reason EBM is open to any intervention as long as they are proven effective through clinical verification. This means that it is open to CAM (complementary and alternative medicine), which is often dismissed by conventional medicine. EBM is also against laboratory study, which is seen as being too theoretical and not relevant to real-world clinical practice.
On the other hand, SBM is focused on mechanisms that can explain the rationale scientifically. SBM is against CAM and is a pro-laboratory study. SBM practitioners believe that basic science considerations should be given greater weight in medical decision-making. As Dr. David Gorski 2) points out, "EBM appears to worship clinical trial evidence above all else and nearly completely ignores basic science considerations."
The difference between EBM and SBM lies in their respective approaches to evidence and scientific inquiry. EBM emerged from post-modernism, while SBM is rooted in the modernism of the 19th and 20th centuries, which had a highly optimistic view of natural science. EBM emphasizes clinical trial evidence and is open to CAM, while SBM emphasizes basic science considerations and is against CAM. As the debate between EBM and SBM continues, it is important for acupuncturist to understand the meaning of evidence in EBM and utilize EBM in their practice for better decision making for their patients.
References
1) Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg. 2011;128(1):305-310. doi:10.1097/PRS.0b013e318219c171
2) https://www.painscience.com/articles/ebm-vs-sbm.php
Further reading;
https://www.painscience.com/articles/ebm-vs-sbm.php
https://www.techtarget.com/whatis/definition/empiricism
https://www.acsh.org/news/2017/03/23/which-worse-postmodernism-or-anti-intellectualism-11040