Bill Benda, MD, Editorial Board Member
Integrative Medicine: A Clinician's Journal
Evidence-based. Once part of an exclusive lexicon of conventional medicine, this lofty directive has found its way into every institution's mission statement within our field, from the Consortium of Academic Health Centers to the Institute of Medicine's 2005 report on Complementary and Alternative Medicine in the United States. Even CAM professions that once rejected reductionist research methodology as inappropriate to their "holistic" philosophy have come to recognize, as well as desire, the credibility that this particular verbal duet conveys.
And they should. Every individual suffering from ill health deserves the assurance that the therapies recommended by his or her practitioner have been tested in an unbiased manner and found to be reasonably efficacious and relatively safe. While advertisements in medical journals are recognized and accepted as mass-marketing strategies, randomized controlled trials in a peer-reviewed publication are vetted by the editorial board and transcend the influence of money and politics. Right?
Not necessarily. "Journals have devolved into information-laundering operations for the pharmaceutical industry," wrote Richard Horton, editor of the The Lancet, in March of 2004. The facts are that the pharmaceutical industry represents a $550 billion retail drug market, and is slated to reach $700 billion in annual sales by 2008. Companies such as Novartis spend 33% of sales on advertising alone (compared to 19% on research and development), and their promotional efforts may not be limited to glossy full-page ads. Two-thirds to three-quarters of the trials published in prestigious journals such as Annals of Internal Medicine, JAMA, and New England Journal of Medicine are funded by the drug industry, and are coincidentally four times more likely to claim favorable results than studies funded by other sources. And the sad truth is that peer review offers no guarantee of academic validity because copious data from multi-center trials can confuse even the most experienced editor.
But the tide is turning for Big Pharma. The public's trust in the industry has fallen precipitously in the past few years; not only because of the recent Vioxx-type debacles, but because the patient has begun to question all aspects of the healthcare system, including us, the practitioners. Our credibility is on the line, and if we make a promise, we had better be able to back it up with more than just a hyphenated adjective. So before we elevate the term "evidence-based" to biblical stature, let us remember that evidence is only as valid as the integrity of those who create it.
1. Horton R. The dawn of McScience. New York Rev Books. 2004;51(4):7-9.
2. El Feke S. A survey of pharmaceuticals. The Economist. 2005, June 18th-24th.
3. Egger M, Bartlett C, Juni P. Are randomized controlled trials in the BMJ different? BMJ. 2001;323:1253.
4. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality. BMJ. 2003;326:1167-1170.