Evidence based medicine – is it

really evidence ?

Prof. Dominic Puthoor

Past president KOA
 Evidence based medicine is
the norm of the day.
Definitely, Meta analysis is the accurate way to judge a topic as it looks
at current and past literature.
This is in contrast to the dogmatic attitude that was prevailing about 30
years back.
 Earlier in our conferences some senior professor will declare
‘In my experience I have done more than 1000 similar cases and I
haven't come across any complication.’

And that is the end of the discussion

Now, such a scenario do not occur. Evidence based medicine made

discussions more transparent and it has tremendous beneficial effects.
At the same time, it has some hidden dangers inherent in it.
It is with the aim of making orthopedic surgeons aware of these dangers, I choose
this topic as the President’s theme.

‘Doctor, aware of your scientific background and

be proud of it’

I stressed this aspect in my presidential address also during

KOACON2016 and was published as an article in KOA journal
Friends,
Practice of any doctor in modern medicine is based on 3 aspects.

1.Sound scientific basis which he had acquired from school and college.
Selection for M.B.B.S is based purely on proficiency in science subjects. It is to make sure that only students with
good scientific background are allowed to study medicine. It is the scientific base that makes a doctor in modern
medicine different from others.

2.Experience he gained over the years. You can call it practice based.
The experience shared by fellow medical practitioners also may be included in this.

3.Continuing education. Any doctor practicing medicine must keep him updated with the latest
development in medical science and technology. This is possible by going through newer editions of text books,
reading journals, attending CMEs, conferences and by hearing medical representatives. Both journals and
medical representatives most of the time highlights statistical data and this is known as evidence based medicine.
Now let us compare and contrast these 3 aspects of medical practice
 Scientific based medicine v/s evidence based medicine

Is evidence based medicine synonymous with scientific based medicine or at least

an extension of it?
No. for example,
there is ample statistical evidence to show Glucosamine and Chondroitin sulphate is useful in the
treatment of osteoarthritis. For a non medical person that evidence is good enough. But for us, who
practice modern medicine, it is not enough. We must understand, on the basis of the science we
studied,
• what is the chemical structure of Chondroitin sulphate?
• How it is split in the intestine so as to get absorbed, what happens to it in the liver?
• Does its structure get altered when it reaches blood?
• Is it possible that it is specifically utilized by the cartilage?
There can be disparity between science and evidence.
What makes Modern Medicine different from Ayurveda?

As it is scientific based, Modern Medicine can easily incorporate advances in other

fields of science and technology.

In contrast to that, Ayurveda have centuries of evidence to support it but it lacks

scientific basis. So fails to progress further.

If evidence wins over science, it is the end of progress

Problem is, data that is provided for statistical analysis can be easily manipulated.
Classical Example is, methyl prednisolone (Solumedrol) in spinal cord injuries.

• Science says steroid knocks out the body’s ability to fight and get
repaired.
• But, we were forced to use it for spinal cord injuries, for about a
decade because of evidence
 This is what happened
Pfizer company did these studies called NASCIS and the person who did these studies is
Dr Michael Bracken. He is not a medical doctor, he is a Statistician. He used evidence
based medicine statistics to prove that Solu medrol helps recovery of paraplegics. Later
it was found that he manipulated the numbers and figures and faked the whole study.

The new analysis of his numbers showed not only that Solu medrol does not work, But
also that it increases mortality rate.

1999 to 2004 Campbell has recommended Solu medrol and we were forced to use it.
But why 2020 Campbell does not tell that this study was fake and fraud?
In this article published in Journal of Orthopedic Association of South Indian States (JOASIS), I have
revealed how industry manipulated data, for their advantage. For lack of time I am not going to the
details. But I humbly request all to conveniently go though this article, published last year, available
online.
 Practice based medicine v/s evidence base

Watson Jones in his classical text book Bone and Joint injuries, contempt operative treatment of
fracture clavicle by saying

‘Nonunion clavicle is rare except when some foolish surgeon do primary operative reduction’

Any orthopedic surgeon with experience of more than 30yrs of practice might have treated at least
1000 cases of clavicle fracture and all of them till recently were treated by fig of 8 bandage or
clavicle brace. Nobody might have thought of any other treatment.

Last 2 decade witnessed AO coming out with specially designed plate for clavicle. Then evidences
started pouring in favour of internal fixation of clavicle.

Internal fixation may be superior. But evidences are appearing so strong; you may be sued for
treating fracture clavicle by brace.
Court (judiciary) look for evidences only.
• They haven’t studied medicine so lacks any scientific basis

• They have haven’t treated any patient so cannot understand practice based
medicine

• As we doctors comes under consumer protection and court is the final authority
in judging our treatment, we are doomed to follow evidence based medicine
A situation is emerging in which you are forced to do your practice, based on
evidence based medicine only and compelled to neglect scientific and practice
based medicine.

All the efforts that were taken to cultivate a scientific mind, during school days and
depth of knowledge acquired in medical sciences, become futile.

All the experience we painfully gained during our practice is also of no use.

We will be forced to look for evidence whenever we treat a patient.

Easiest way to get in touch with evidence based medicine is through a
representative of medical and surgical industry

Industry dictate what the treatment is.

This is a situation any doctor with self esteem will find difficult to
digest.
Dear Doctor

Next time when you are introduced to a new product whether it is a drug or
equipment, analyze with your scientific mind and take a decision.

if you came across a newer method of treatment, don’t accept it blindly.

Let not industry be your master.

• Let our association meetings and annual conferences be venues for
sharing our experience.

• Let our discussions be more scientific based than evidence based.

• Let the aim of our journal be to propagate personal experiences and

observations of its members rather than analyzing evidence available
in other journals.