In the 1980s, healthcare made a concerted effort to move towards evidenced based medicine. That the treatment a doctor prescribed should be backed by research, meaning (ideally) randomized controlled trials, placebo groups, large sample sizes, independent researchers.
Yes, incredibly, this was not already standard. Not that everybody is doing it these days, but the idea was to move away from intuition and anecdotal experience as one’s primary basis for treatment.
Again, it’s true not everybody is big on this. The personal training world is still HEAVILY influenced by n = 1, that is, a single person’s experience. Many personal trainers train their clients solely based on how they’ve trained themselves. It’s the biggest mistake trainers make, and it’s voluntary. The average trainer recoils upon seeing an abstract, much like a craft beer drinker recoils when seeing a Miller Lite can. “Just eat less and move more.” Or “Just kick the client’s ass. It’s not complicated.”
Older practitioners are notorious for this too. What was evidenced based when a doctor was in his 30s has become outdated by the time they’re in their 60s. But it’s too hard to change. Too much effort to alter your habits when seeing a patient. Too much energy to keep up with the literature.
-> When looking for a doctor, part of your criteria should be picking one who is old enough to be experienced, but not old enough to be jaded. All else being equal, on average you want your say, surgeon, 45 years old.
This is how many parents are. The most common phrase of old parents to new parents is,
[new parent states new approach]
“Oh, we did [old approach], and my kids turned out fine.”
It’s terrible logic. Just because someone turned out fine does not mean what you did was ideal. We’re rarely dealing with right or wrong here. We’re dealing with trying to get less and less wrong.
On the other end of the pendulum, you have those who OBSESS over needing a research citation for every decision. They completely discount anecdotal experience and human intuition. Declaring any person with a contrary opinion or experience to a study as fooling themselves, falling into some Daniel Kahneman bias, or being an idiot. I call these people research nazis.
One reason I disdain the research nazi is because they act as if science is flawless. Yet most research is not randomized, has small sample sizes, doesn’t account for the difference between statistical and clinical significance, biased by funding or researcher influence, has statistical sections math majors can’t even follow.
If you’re going to accept humans are flawed when it comes to decision making, you have to accept research is flawed, because it’s done with human decisions. Sure, perhaps one is less flawed than the other, but we can’t just dismiss the other end of the spectrum because there isn’t a peer reviewed meta review fully backing it up.
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MATH ain’t fail-proof either
I’ve had a lot of clients who are engineers. They’re some of my favorites. However, one trait of theirs, along with many of their ilk, is they love numbers. Sometimes too much. You may have heard some version of “People lie; numbers don’t.” Or “I don’t like to deal with opinions. I like data.”
Anybody who is a slave to data truly does not know what they’re talking about.
I was a mathematics major for two years, eventually deciding to stop to get a minor. You learn funny things about numbers when you get to that level.
The biggest of which is math is created by…humans. While in a sense obvious, many don’t truly understand this facet of mathematics. It’s common thinking math is some hidden language of the universe. Like it’s electricity. That it’s always been there, but one day we discovered it.
We did not discover math. We invented it. It just happens to be we’ve invented it in a way where we more often than not see no fault with it. Where we’ve ironed out all the problems, where the equation is flawless. Until you get to a higher level.
You’ve likely heard of Isaac Newton. He created the “laws” of motion. Yet the reason Einstein is famous is because he found some scenarios where these laws weren’t true. For instance, Newton’s world says time is absolute. It always moves in the same manner. Einstein discovered that’s wrong. Time is relative. The faster you go, the slower time goes.
–Can special relativity explain any of the life extending benefit of exercise?
Einstein thought the world was fully predictive. If you do X, Y will happen. When what you’re dealing with is really big, like planets, Einstein’s approach works. When what you’re dealing with is really small, like electrons, then quantum mechanics shows if you do X, Y or Z will happen, with respective probabilities. Einstein was wrong.
These are the most acclaimed minds of human history. Yet their inventions are not fail-proof. Their theories break down in specific situations.
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Here is one to truly jack your mind up: You’ve probably heard there are infinite points on a line, right? That is, take a line, and you can make any given point infinitely small, causing all the points on that line to add up to infinity.
Alright, now take a bigger line. Say it’s twice the size. How many points are on that line? Also infinity!
In math, two different sized lines have the same number of points!
Math is not fully rigorous. Human research, besides its obvious human flaws, is thus not either, because it is based on a discipline, mathematics, which itself is not fully rigorous. I mean, how would you do a research study without math??
We can’t be pretentious with our judgment, but neither can we with research. Yes, on balance, give me research over opinion, because research is often less wrong than a single person’s intuition. But it’s nowhere near as “right” as mathematical theory is, which itself is not always consistent.
Research is not perfect, and once in a while a person comes along who shows exactly how and why that research we all thought was largely correct, is in fact correct, yet still wrong. Newton’s notion of time is “correct”, that is, it works, the majority of the time. For 99.99% of experiences, we don’t need Einstein’s interpretation. Newton is good enough. You want GPS though? Where a satellite is going around the Earth at thousands of miles per hour? Then we need Einstein.
Many times when someone is shitting on either research or a given person’s experience, they’re not fully understanding the context a theory is being given in. Yet the context is as important as the theory. And regardless, it is guaranteed a theory will break down in some context. It is impossible a given theory is fully correct…it’s also unlikely a given theory is fully wrong.
With math, we tend to be talking in the 99 percentiles of being correct. It’s why math is the most amazing invention in the history of humankind.
-> Some may debate language is more important, but seemingly all species have invented their own language. Only one species has invented mathematics, with results speaking for themselves, as virtually everything around you is rooted in math.
Or you could simply view math as a specific language.
But math is not fully provable, fully consistent, fully complete.
-> For more of a mind bend, check out Godel’s Incompleteness Theorems. Where ironically, math is used to prove math is not, and can never be, complete. These are some solid layman’s explanations. (I like Edwin Chen’s best.)
With most human modeling, many of us are ecstatic if a theory works 60% of the time. Ten percent of smokers get lung cancer. Ten percent! But that’s enough for us to castigate smoking. Yet there are those out there who bitch not every study backs up a theory. Or a theory is flawed, so it’s useless.
- If math is flawed, does any modeling involving humans even have a chance of not being flawed?
- Even if you think math should be the barometer, good luck finding mathematical probabilities with humans!
RK Reddy
October 19, 2017
If you don’t mind sir. This is my sir/ mentors opinion sir…
I don’t mean offending you sir.
” In fact the author of this article conveniently forgets that evidence based medicine dies not just mean evidence from research publications it actually means the intersection and convergence of Physician’s wisdom based on intuitive understanding of biology,patient’s preferences and evidence from published literature.No rationally scientific person ever tries to just base their decision on one parameter alone and multiple factors are factored- in beore a balanced decision is made in choosing to diagnose and treat.One has to remember that egos and personal biases apart one had to understand science in its true spirit and avoid falling prey to the attraction of holding on to extreme opinions and views.The balance is never at the extremes, it is always at the centre-at the convergence of multiple factors-no one factor can ever be considered better or more important than the others and so is the case in evidence based medicine;it does not mean publications based medicine alone -if it is thought like that by someone it is puerile thinking.The deeper meaning and the actual meaning of evidence based medicine is convergence of physican wisdom+patient preference+evidence from research. Being anti research is understandable but it is dangerous and is equal to quackery and superstition.Research may not be and will never be perfect but research had the audacity abd grace to accept that mistakes do happen and corrections need to be made;whereas eminence and emotion based quackery medicibe is more authoritative, arrogant,abusive and averse to change;thus jeopardising the health of vulnerable patients forever. “
b-reddy
October 20, 2017
Hey RK,
Not offended at all. Disagreement is welcome. Though what your mentor is saying is largely a rephrasing of what I said.
I’ll interject a couple places,
This is a silly technicality argument, but I’ll address it. I never said the definition of evidenced based medicine is solely research and disregards any clinical judgment. I referred to the research aspect of it, and how that gets carried away. The rest of the comment echoes my sentiment- we shouldn’t get carried away with literature’s importance.
That said, the clinical judgment aspect of medicine has always been there. The move to evidenced based primarily refers to making medicine more research based. If there are three pillars,
Patient preference and physician wisdom were always there. The fact is, at least in America (I appreciate there could be country differences here), when the literature talks of evidenced based practice, we are overwhelmingly referring to practice which is grounded in research. Patient and physician preference are implicit.
I have a feeling this just not well written, because it’s nonsensical. Some factors are of course more important than others. For example, if you take an end of life patient, where the physician’s wisdom says to treat, the evidence says to treat, but the physician’s preference is religious and says to not treat, then the patient wins. There are infinite scenarios where one factor will dominate.
Another easy example- for personal training, what I do, there is often little evidence in how to handle a particular client’s situation. Exercise science just doesn’t have that kind of research. At least not yet.
So when I get a 50 year old, recently divorced, pre diabetic, thinking about a career change, achey knees but healthy shoulders, practitioner judgment predominates the approach. Thus, it’s a more important factor. And if the client simply refuses to do something I ask of them, even if all my judgment says we should be doing it? Then their judgment wins as most important factor.
RK Reddy
October 21, 2017
Hi there Brian. So the arguments are like two sides of the same coin…
Thanks and regards.
b-reddy
October 22, 2017
Good way of putting it!
Dr. J
November 4, 2017
“When looking for a doctor, part of your criteria should be picking one who is old enough to be experienced, but not old enough to be jaded. All else being equal, on average you want your say, surgeon, 45 years old.”
Agreed. When I look for a doctor for myself, I try to find one ~ 10 years out of training for the same reasons you listed. Fresh enough to be familiar with the new literature and innovations, but has a few years and cases under the belt. Most importantly, also has a higher likelihood of being a Dr. McSteamy/ McDreamy.
“One reason I disdain the research nazi is because they act as if science is flawless. Yet most research is not randomized, has small sample sizes, doesn’t account for the difference between statistical and clinical significance, biased by funding or researcher influence, has statistical sections math majors can’t even follow.
If you’re going to accept humans are flawed when it comes to decision making, you have to accept research is flawed, because it’s done with human decisions. Sure, perhaps one is less flawed than the other, but we can’t just dismiss the other end of the spectrum because there isn’t a peer reviewed meta review fully backing it up.”
Agree here as well. In addition there is a growing problem in academic journals of cherry picking. Only negative results are eschewed, only positive results are published, if an article is of insufficient quality/caliber/rigor to be featured in a more stringent journal just keep applying down hill until someone says yes instead of trying to write a better paper, etc. There is a growing body of literature (coincidentally) recognizing this as a significant concern.
b-reddy
November 5, 2017
Good point about journals. The more the research revolves around humans, the more true that seems to be.
I’ve found the more research I read, due to learning various tricks of the trade, the more convoluted I find it to be. The more convoluted any given study is, the more I think some kind of machination took place to get the study published.
I’m not even sure peer reviewed has much significance these days. I have an old doctor I train. Every now and then he points me to a study from 50 years ago. Granted, we tend to be dealing with more complex matters now, but it’s amazing how much easier older research is to read. It’s actually borderline enjoyable. Now you have to take huge parts of a methods section on faith.
I wonder if one segment of the reproducibility issue is other researchers can’t even fully decipher what a given study did, thus they can’t reproduce it.