Evidence-based vs. empirical medicine

Steer away from medicine based purely on testimonials. 

I often have stated in my various writings that I try to practice evidence-based medicine. It occurred to me that a reader might ask, “What is that?” Or, “As opposed to what?”

Evidence-based medicine is medical practice based on the traditional scientific approach of posing a question, formulating possible answers, then studying the issue in rigorous, objective laboratory research and clinical studies on large populations of patients. The results of these studies should be verifiable and reproducible by others. Commercial and personal bias should be absent from the process. Evidence-based medicine should provide guidelines for safe and effective treatment of patients across a broad swath of society. It is your protection against quacks, charlatans and snake oil salesmen. 

Empirical medicine is the opposite. It is medicine by testimonial. It reflects the individual’s experience, whether patient or doctor. Each patient presents a unique set of circumstances, which is why so many medical conditions can present in multiple ways. Many patients, alternative medicine practitioners and even some physicians try to extrapolate those individual circumstances to make broad generalizations, without resorting to a proper examination of the problem, seeking consensus from other practitioners or searching medical literature for relevant studies. 

Put another way, evidence-based medicine applies a proven, broad fund of medical knowledge to the individual whereas empirical medicine takes the experience of an individual and tries to apply it to large groups. In medical school, we were not subjected to a parade of individual patients giving us testimonials of their unique experiences. We learned based on the accumulated wisdom of our medical predecessors who did the necessary studies and documented this in textbooks and medical journals. 

Of course, with the exception of public health, the delivery of medical care is not to large populations of people. Distilled to its essence, medical care is delivered individually, one patient at a time. The newly trained doctor takes all of this education and begins to apply it to his or her patients, one by one. He or she soon learns the nuances in how diseases present, the patient idiosyncrasies that bear on the signs and symptoms of various illnesses, variations in laboratory test results and the highly individualized response of patients to treatment. A 99 percent effective medicine or operation means that 1 percent of people out there will not respond to it. Learning this is part of the “art” of medicine. 

Skilled, compassionate physicians care about their patients and treat them as individuals. They do so, however, within the framework of a broad fund of strictly objective knowledge coupled with experience. They know that not every patient with the same illness will present or respond to treatment in the same way. They listen to the patient and remain supportive—they may even develop personal bonds with their patients—but they do not abandon evidence-based treatment simply because they are sympathetic. This may cause some patients to feel that the physician just doesn’t “get them,” which pushes them to nonphysician practitioners who present themselves as more supportive and who will treat them based on their unique complaints. Fringe and alternative medicine practitioners, such as naturopaths and homeopaths, thrive on such patients who feel that traditional medicine has failed or abandoned them. 

A prime example of the dangers of empirical medicine is the debacle of laetrile, a drug derived from the pits of fruits such as apricots. Laetrile was promoted primarily by nonphysicians, but by a few physicians as well, for the treatment of various cancers. It reached its height of popularity in the mid-1970s but never was approved for use in the United States. The number of patients demanding laetrile and crossing the border into Mexico to get it grew due to patient testimonials that it worked until it could no longer be ignored. 

Advocates of laetrile accused organized medicine of withholding information on laetrile and obstructing its approval in the United States to protect its monopoly on lucrative cancer treatments. Eventually, respected medical centers did the studies and reported their results on laetrile, showing it had no efficacy whatsoever in treating any cancer. Laetrile, finally, joined bloodletting and purging in the dustbin of discredited medical treatments. How many died from choosing laetrile over evidence-based treatments will never be known. Of course, a few die-hard conspiracy theorists will always believe that laetrile was just another victim of organized medicine’s stranglehold on medical care in the United States. 

Practices such as Chinese medicine, homeopathy, naturopathy, reflexology, kinesiology, chiropractic, aromatherapy, salt rooms, colonic cleansing and others rely primarily on the testimonials of satisfied patients. When you begin looking for proof of efficacy, it is not to be found in peer-reviewed, scientific medical journals. Medicine based on testimonials and empiricism, rather than on evidence-based science, ceases to be art and science. It becomes merely art.