Wednesday, July 22, 2015
There is (No) Evidence For That: Epistemic Problems in Evidence Based Medicine
Below is a Power Point Presentation that I have delivered several times recently including one iteration at the SMACC conference in Chicago. It addresses epistemic problems in our therapeutic knowledge, and calls into question all claims of "there is evidence for ABC" and "there is no evidence for ABC." Such claims cannot be taken at face value and need deeper consideration and evaluation considering all possible states of reality - gone is the cookbook or algorithmic approach to evidence appraisal as promulgated by the User's Guides. Considered in the presentation are therapies for which we have no evidence, but they undoubtedly work (Category 1 - Parachutes) and therapies for which we have evidence of efficacy or lack thereof (Category 2) but that evidence is subject to false positives and false negatives, for numerous reasons including: the Ludic Fallacy, study bias (See: Why Most Published Research Findings Are False), type 1 and 2 errors, the "alpha bet" (the arbitrary and lax standard used for alpha, namely 0.05), Bayesian interpretations, stochastic dominance of the null hypothesis, inadequate study power in general and that due to delta inflation and subversion of double significance hypothesis testing. These are all topics that have been previously addressed to some degree on this blog, but this presentation presents them together as a framework for understanding the epistemic problems that arise within our "evidence base." It also provides insights into why we have a generation of trials in critical care the results of which converge on the null and why positive studies in this field cannot be replicated.