Here is an analysis of the underlying causes of healthcare harms and misdiagnosis from Juan from the EBM mailbag discussion list yesterday, and below my attempt to re-phrase this in terms of processes:
-yes, Owen, apparently, EBM has only benefits without harms
-but, how can we “believe” in the application of EBM in the consultation room, in front of the clinico/statistical tragedy 1/ many doctors do not understand health statistics http://library.mpib-berlin.mpg.de/ft/gg/GG_Helping_2008.pdf
2/ many doctors do no know about their patients’ culture, expectations and values http://pubmedcentralcanada.ca/pmcc/articles/PMC4484696/
and 3/ many doctors ignore the principal/agent theory and how to stand in “another’s shoes” so they practice “defensive medicine” (“offensive” from my point of view)
-we need to be more critic with guidelines that have, as in this example, only 9–12% based on the best quality (Grade A) evidence https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245184/
-EBM is a god that justify anything in its implementation
Your very useful analysis points us towards some of the most important processes that are contributing to healthcare harms and misdiagnosis.
I paraphrase your analysis here as key processes and possible key sites of intervention:
1) the education of healthcare workers,
2) the political (de-)regulation of harmful healthcare interventions (the ‘weak’ guidelines as they are euphemistically called), and
3) the power of, and use of rhetoric by, experts (including e.g. GPs) to impose these on unsuspecting patients.
The belief of experts in the implementation of EBM is underpinned and dominated by a dominant rational positivist empiricism with a hat tip to ‘values’ (Howick, 2011). Because of this EBM has become a means of production for capitalism. And it is this, ideological, process that produces the predominantly maximalist and technologist mindset described by Groopman. This is the mindset that produces so much harm and misdiagnosis.
I suggest that EBM’s fatal flaw, the crisis of EBM, is the failure to consider that ideology in capitalism may be the site of formation of the mindsets, and therefore the values and beliefs, of both experts and patients (Greenhalgh et al, 2014; Kelly et al, 2015). And that it is the mechanisms of ideology in capitalism that requires analysis. But there is a kind of mental block resisting this.
Greenhalgh, T., Howick, J., & Maskrey, N. (2014) Evidence based medicine: a movement in crisis? BMJ, 348.
Howick, J. (2011) The Philosophy of Evidence Based Medicine. Chichester: Wiley-Blackwell.
Kelly, M.P., Heath, I., Howick, J., & Greenhalgh, T. (2015) The importance of values in evidence-based medicine. BMC medical ethics, 16(1): 69.