In a recent post I said that med school professors cared about process (doing things a “correct” way) rather than result (doing things in a way that produces the best possible outcomes). Feynman called this sort of thing “cargo-cult science“. The problem is that there is little reason to think the med-school profs’ “correct” way (evidence-based medicine) works better than the “wrong” way it replaced (reliance on clinical experience) and considerable reason to think it isn’t obvious which way is better.
After I wrote the previous post, I came across an example of the thinking I criticized. On bloggingheads.tv, during a conversation between Peter Lipson (a practicing doctor) and Isis The Scientist (a “physiologist at a major research university” who blogs at ScienceBlogs), Isis said this:
I had an experience a couple days ago with a clinician that was very valuable. He said to me, “In my experience this is the phenomenon that we see after this happens.” And I said, “Really? I never thought of that as a possibility but that totally fits in the scheme of my model.” On the one hand I’ve accepted his experience as evidence. On the other hand I’ve totally written it off as bullshit because there isn’t a p value attached to it.
Isis doesn’t understand that this “p value” she wants so much comes with a sensitivity filter attached. It is not neutral. To get it you do extensive calculations. The end result (the p value) is more sensitive to some treatment effects than others in the sense that some treatment effects will generate smaller (better) p values than other treatment effects of the same strength, just as our ears are more sensitive to some frequencies than others.
Our ears are most sensitive around the frequency of voices. They do a good job of detecting what we want to detect. What neither Isis nor any other evidence-based-medicine proponent knows is whether the particular filter they endorse is sensitive to the treatment effects that actually exist. It’s entirely possible and even plausible that the filter that they believe in is insensitive to actual treatment effects. They may be listening at the wrong frequency, in other words. The useful information may be at a different frequency.
The usual statistics (mean, etc.) are most sensitive to treatment effects that change each person in the population by the same amount. They are much less sensitive to treatment effects that change only a small fraction of the population. In contrast, the “clinical judgment” that Isis and other evidence-based-medicine advocates deride is highly sensitive to treatments that change only a small fraction of the population — what some call anecdotal evidence. Evidence-based medicine is presented as science replacing nonsense but in fact it is one filter replacing another.
I suspect that actual treatment effects have a power-law distribution (a few helped a lot, a large fraction helped little or not at all) and that a filter resembling “clinical judgment” does a better job with such distributions. But that remains to be seen. My point here is just that it is an empirical question which filter works best. An empirical question that hasn’t been answered.