Evidence-based medicine? Not so much.

Is Evidence-Based Medicine Evidence Based?

Overdosed America: The Broken Promise of American Medicine
by John Abramson
(New York: HarperCollins, 2004), 352 pp., $24.95

According to the U.S. Centers for Disease Control and Prevention, of the 2.4 million U.S. deaths in 2000, 400,000 were associated with unhealthy diet and lack of physical activity. These are deaths related to the particular way in which civilization has “progressed” upon this planet: high-fat, high-carbohydrate fast foods devoid of fruits and vegetables; a vast multitude of automobiles that make self-propulsion (walking) obsolete as a standard life routine; and couch-potato-creating television sets that not only replace the neighborhood kickball game and hide-and-seek activities that amused me when I was a kid, but also badger us to purchase those same automobiles and eat those same fast foods.

How has the trillion-dollar-plus enterprise we call the health care system responded to this pervasive undermining of our health? By offering more inventions, which—like those cars, fast-food chains, and TV sets—are capable of making money for a small stratum of society. Instead of approaching the health effects of modern civilization through community-wide and public health interventions—banning cars and creating greenbelts within cities, spending more dollars on health education than the food industry spends on advertising, and creating more neighborhood physical activity programs than the auto industry creates cars—we have chosen to address those 400,000 deaths with a few rushed minutes in a sterile exam room populated by a highly trained physician, a passive patient, and a prescription pad.

John Abramson is a physician who spent more than twenty years in those exam rooms, filling out thousands of those prescription pads. But something happened to him that, sadly, happens to few physicians. He began to study epidemiology and research methodology, expanding his viewpoint from a close-up focus on the individual patient to a panorama of the entire population. Carefully reviewing the research literature, he found that spin doctors had been doctoring the evidence. The conclusions he reached from his careful literature review differed from the conclusions published by the authors of the universally accepted clinical practice guidelines—the “evidence-based medicine”—that are the yardsticks against which physicians’ quality of care is measured…

Overdosed America presents a strong indictment of the evidence that dictates medical practice, a challenge that is credible only because Abramson backs up his statements with detailed analyses of the prevailing evidence. It is beyond the purview of this review to judge whether each of Abramson’s conclusions are scientifically and statistically valid. What can be said, however, is that the seriousness with which he explores clinical issues merits a major debate on those issues within the world’s leading medical journals—untainted by the almost ubiquitous monetary distortions…

Why this lengthy exposition of a clinical issue in a health policy book review? Because readers who might be inclined to view Overdosed America as simply another in the growing number of diatribes against drug companies should be aware that this book makes its arguments in a detailed, well-referenced manner. Moreover, responsibility for the overdosing of America goes far beyond the drug industry, resting equally with the nation’s physicians. I beg all of my physician colleagues to read this book and to think deeply about how we are practicing our chosen profession.

Thomas Bodenheimer

Editor’s Notes

Thomas Bodenheimer ([email protected]) was a private primary care physician for twenty-two years and is now on the faculty of the University of California, San Francisco.