Evidence-based medicine has been hijacked: a report to David Sackett

Abstract
This is a confession building on a conversation with David Sackett in 2004 when I
shared with him some personal adventures in evidence based medicine (EBM), the
movement that he had spearheaded. The narrative is expanded with what ensued in
the subsequent 12 years. EBM has become far more recognized and adopted in many
places, but not everywhere, for example, it never acquired much influence in the
USA. As EBM became more influential, it was also hijacked to serve agendas
different from what it originally aimed for. Influential randomized trials are largely
done by and for the benefit of the industry. Meta-analyses and guidelines have
become a factory, mostly also serving vested interests. National and federal research
funds are funneled almost exclusively to research with little relevance to health
outcomes. We have supported the growth of principal investigators who excel
primarily as managers absorbing more money. Diagnosis and prognosis research and
efforts to individualize treatment have fueled recurrent spurious promises. Risk factor
epidemiology has excelled in salami-sliced data-dredged articles with gift authorship
and has become adept to dictating policy from spurious evidence. Under market
pressure, clinical medicine has been transformed to finance-based medicine. In many
places, medicine and health care are wasting societal resources and becoming a threat
to human well-being. Science denialism and quacks are also flourishing and leading
more people astray in their life choices, including health. EBM still remains an unmet
goal, worthy to be attained.

This conversation with David Sackett started in 2004, at a retreat somewhere

in the English countryside, when we met as part of the International Campaign to
Revitalise Academic Medicine (ICRAM). ICRAM was an ambitious project by well-
meaning people to change academic medicine. I suspect that we failed magnificently,
in due proportion to our utopian ambition. I shared with David somepersonal
adventures in EBM. There he was, a master listener, a wonderful living mirror to talk
to. Those who did not have the chance of interacting with him may still benefit from
the excellent series of articles on mentoringthat he wrote with Sharon Straus.
Over the following 12 years, this conversation has continued to grow in my
mind, adding new chapters to it, as I have accumulated more defeats. Defeats that I
have wanted to share with David Sackett even in absentia. David, I am a failure. I
had long heard about your legacy: at age 32 you had been recruited to a rather
unknown medical school in a small city built on the shores of a lake to start a
department of clinical epidemiology and biostatistics, the first of its kind in the world.
Three decades later I was one of those dangerous 32 (standard deviation 6 ) 6 year
olds who you had inspired. At the age of 32 years, I was offered to lead a department
of the same kind at an even more unknown medical school in a smaller city built on
the shores of a much smaller lake. Being a dual citizen, a weird none evidence-based
prerequisite for getting a faculty position in a public university was to serve 6 months
in the army. During these 6 months, I wrote lots of desperate poetry, some articles,
and a 350-page book on Principles of Evidence-Based Medicine in Greek. You are
largely to blame for this latter composition.
Several window panes were missing in the on call room, but hopefully, Greece
is not as freezing as Ontario most of the time. One broken window actually had a nest
of wasps attached, so one could often find an occasional wasp in the bedsheets. We
hospitalized mostly young recruits who had gone crazy during their military service.
One of them was roaming outside playing precariously with a lighter whenever it was
windy. He was eager to put the surrounding forest of pine trees on fire, burn down our
19th century neoclassical hospital building, and get revenge for losing his mind.
Sometimes, I was thinking whether people see EBM as an incendiary risk and
EBMers as lunatics threatening to burn to the ground the dilapidated neoclassical
building of medicine.
EBM met with substantial resistance in the 1990s and 2000s. Even in the
USA, the mecca of biomedical research, EBM, and any serious biomedical research
that may help intact humans was largely unwanted. As a clinical researchfellow, I
remember that every week we were waiting to hearwhether the Agency for Health
Care Policy and Research (AHCPR, which subsequently became AHRQ) would be
axed. AHCPR/AHRQ survived, but has always had to fight valiantly for its existence
since then. EBM is widely tolerated mostly when it can produce largely boring
evidence reports that are shaped and endorsed by experts. More than 7 billion of
people would be better qualified than me to lead expert-based activities. But let me
flash back to Europe and the late 1990s.
When I was appointed as faculty, I felt even more of an outcast. At faculty
committees and assemblies and prestigious societies in continental Europe, when
some senior academic opinion leaders wanted to spit and curse, they would use
instead the words meta-analysis and EBM. When I published a story in the
Christmas BMJ on how physicians are treated by the pharmaceutical industry with
free lunch vacation with full entertainment in the Arabian peninsula, a powerful
politically connected syndicalist doctor in Athens wrote to the medical society asking
for my exemplary punishment and revocation of my medical license. He also attacked
me personally at the board of directors of the national disease control center where I
was vice president.
The same people who were previously spitting when mentioning EBM
started using the very same term to buttress their eminence-based medicine claims to
prestige. Several senior people started to ask me to work with them, hoping that they
would publish articles in major journals. Saying no and trying to stick to high
standards for my work bought me even more enemies, including leaders of academia,
politics (of the entire corrupted range of left-right spectrum), and academic politics.
Even the syndicalist who had once tried to annihilate me reapproached me: John, we
all know that you are the best scientist in the country. Why dont we work together?
You know how successful I am. He presented a long list of his power attributes and
connections. The catalog was stunningly impressive.
A senior professor of cardiology told a friend of mine that I should not be too
outspoken; otherwise, Albanian hit men may strangle me in my office. I replied that
they should make sure to get correct instructions to my officed turn left when they
come up the stairs. The same people who were previously spitting when mentioning
EBM started using the very same term to buttress their eminence-based medicine
claims to prestige. Several senior people started to ask me to work with them, hoping
that they would publish articles in major journals. Saying no and trying to stick to
high standards for my work bought me even more enemies, including leaders of
academia, politics (of the entire corrupted range of leftto- right spectrum), and
academic politics.
As for epidemiology, risk factors for disease are becoming more dangerous
than ever. By this, I mean two things. First, strong risk factors with unquestionable
evidence like smoking are killing now globally more people than ever. Second,
instead of dealing with these major public health risks, the production of spurious,
false-positive, or confounded putative risk factors is more dangerous than ever.
Jumping from correlation to causation , data dredging is called causal evidence and
fuels guidelines. Most data and protocols are not shared. Most studies have no
prespecified protocols and analyses anyhow. Although team work and large consortia
have improved enormously the quality and reproducibility of work in some fields of
epidemiologic investigation, some others have promoted mostly massive gift
authorship. There are also so many quacks ranging from television presenters and
movie stars turned into health trainers and pure science denialists (e.g., climate, HIV,
vaccine denialists, and religious fundamentalists) that one has to tread carefully. We
should avoid a civil war on how to interpret evidence within the health sciences when
so many pseudoscientists and dogmatists are trying to exploit individuals and
populations and attack science. However, too much medicine and too much health
care is already causing harm.
The GDP devoted to health care is increasing, spurious trials, and even more
spurious metaanalyses are published at a geometrically increasing pace, conflicted
guidelines are more influential than ever, spurious risk factors are alive and well,
quacks have become even more obnoxious, and approximately 85% of biomedical
research is wasted. I still enjoy science tremendously, focusing on ideas, rigorous
methods, strong mathematics and statistics, working on my weird (and probably
biased) writings alternating with even more desperate poetry, and learning from
young, talented people.-five years after its launch, EBM should still be possible to
practice anywhere, somewhered this remains a worthwhile goal.