How Do We Approach Problems & Choices in Life?
When you’re trying to find an answer to a problem that you don’t know much about, what do you normally do? Most of us “ask around”, see if any family members, friends or someone who we respect has some ideas. Or we might start looking in books or online review or answer sites like Wiki-Answers and so on. We might also look around for testimonials from people who look like they really tried something and are writing about it honestly, hoping it’s not a paid advertisement or possible fake.
When the problem is what kind of car we should I buy, we pretty much decide what we “like” and then we might look at Consumer Reports and things like that to see what products match up with our needs and requirements. We might match up the looks with our likes, then start looking up what the repair record is, resale value and things like that. We then find some happy and unhappy customers who have written reviews somewhere and decide who we want to believe. Then it’s time to go shopping for the best price. Even then, have you ever been stuck with a lemon even after your best efforts?
While the above might work for pretty basic things like buying a car, is this a good way to find the best solution to some of your biggest health issues? Even with the above example, which does not really compare to a significant health problem you might have, do you want to trust “opinions” or “testimonials” from people you don’t know? Even if you “know” someone, are their likes and dislikes and requirements the exact same as yours? Of course not! So if you really want as much objective verifiable information as possible, at some point, you look at something like Consumer Reports and CarFAX to help you decide.
So, I want you to consider this. Is finding a solution to your health problem LOWER on your list than buying a car or some other product? I certainly hope not, or perhaps your health and current problem is not that big of a problem for you after all. If it IS a big problem, what you read here will help you IMMENSELY to get to a solution that actually works as quickly as possible! Less messing around with things that don’t work!
Why do we trust Consumer Reports and CarFAX and consumer advocacy organizations of this type? They pretty much put their reputation on the line and document how they gather information from many sources to give you the most accurate objective picture on cars or other products as possible. These are not a collection of opinions, but rather a record from sources that measure what has happened to the car you are looking at or cars that are just like it.
When you’re ready to put down a significant chunk of money on the table for that new car, would you rather know what the track record is on that type of car (repairs, gas $$ useage, resale value, etc.) or would you simply take an opinion from someone you know or don’t know saying that the car’s a “good one”. Consider this. Even if the car’s been a “good one” for that person who gave you the opinion, are all cars the same? Is it possible that the one you are going get is not the same and might have all sort of problems? How do you find out what the chances are that this might happen? Well, in the case of cars, something like Consumer Reports might be the ticket for you.
The human body is WAY more complex than a car or any other product you can buy. There are a lot more variables and ways that the many trillions of cells in your body work in sickness and in health. So you’re not going to find a Consumer Reports for humans, or even human body parts. There are simply too many variable to keep track of and report, but there is a great alternative to this for specific problems. It’s called Evidence Based Medicine or EBM for short. It’s the direct opposite of “seat of the pants” or “eminence based” medicine, which means finding things out and getting treatment based on opinions and trial and error. Both mainstream and integrative as well as alternative practitioners are guilty of this, at YOUR health’s expense!!
Evidence Based Medicine is relatively new to healthcare, and it is quite possible your doc is still practicing seat of the pants medicine. While EBM is heavy on statistics and clinical trials and stuff like that, the good news is that you don’t have to know how to do all that. All you need to know is the basics of how it works, why it is the best information you could possibly have, how it applies to natural and alternative health as well as mainstream Western medicine. For doctors, it is called EBM. For the rest of us that need real answers to real problems pronto, I call it Evidence Based Healthcare Information or EBHI.
The beauty of this concept is that it is not isolated to a single field. It is a collaboration of techniques from science, engineering, and statistics, which means it is hard to punch holes in the proof that it generates. You may not like it, and it may not fit with what you think, but it is objective and solid. Evidence based tools include systematic review or meta-analysis of medical publications, risk-benefit assessment, and the gold standard randomized controlled trials for the highest proof or Level I evidence. There are other levels of evidence, and these will all be covered.
The LOWEST form of “evidence” or proof in healthcare are opinions and statements by the “medical expert”, usually the doctor. This is really “seat of the pants” medicine if personal experience and trying to remember what was taught in medical school and residency is all the doctor used to offer treatment options. If you think about it, it is sort of like offering testimonials as the basis for your recommendation. In this case, the testimonials are a vague memory of what the doctor thinks may have worked in the past and continuing to do the same without looking at the newest and best available evidence or proof. This is NOT to say that experience is not necessary or unimportant. It is! However, this experience should be used to determine if the patient sitting in front of them would benefit from Evidence Based Health Information research results or not. This is where the art of medicine is still quite important.
Basic EBHI Grades and Levels
One of the first ratings were based on the United States Preventive Health Services Task Force as follows:
- Level I: Evidence obtained from at least one properly designed randomized controlled trial (RCT).
- Level II-1: Evidence obtained from well-designed controlled trials without randomization.
- Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
- Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
- Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
To explain a little bit, an RCT is considered the highest form of evidence and is the gold standard for conventional or mainstream medicine. We will explore how all of these ratings arguably need modification for natural and complementary therapies. An RCT means a head to head comparison of Treatment A versus Treatment B, one of which MAY be a placebo. Further more, who gets Treatment A or B is decided “blindly” by a computer using pure chance sequence of numbers so that there is no bias. The trial is often also “blind” in the sense that the treatment team and doctor may not know which patient is getting which treatment. Bias means some factor, like a doctor’s opinion about who should be on one treatment or the other, which can unintentionally alter the study results. It may sound cold and impersonal, but it is the most reliable way to determine if one treatment is better than another, hands down, based on time honored statistics principles.
Case control and cohort research studies are epidemiologic and using some pretty complex statistics figure out how to compare a bunch of people who have received a treatment, taken a supplement or were exposed to something versus those who were not. One looks into the future and one is based on things that have happened in the past, compared to people who did not take something, like a drug or nutrient, or were not exposed to something, like a toxin. Many natural treatments have this level of evidence supporting them and need more research for better proof.
Time series is nothing but a collection of people that have taken something or been exposed to something. The series may not even contain ALL of those that received the treatment, but rather just some of them. Think of this as a collection of people who were observed and maybe given testimonials that something works.
“Expert” opinion is the lowest form of proof because it is often difficult to establish who is an expert and it is also basically based on seat of the pants experience ONLY! So, while this may be better than nothing, it is sometimes totally misleading.
A second form of rating is based on the UK National Health Service and is very similar:
- Level A: Consistent Randomised Controlled Clinical Trial, cohort study, all or none (see note below), clinical decision rule validated in different populations.
- Level B: Consistent Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes Research, case-control study; or extrapolations from level A studies.
- Level C: Case-series study or extrapolations from level B studies.
- Level D: Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles.
There are refinements which look at details even deeper. For example, were all the studies at least showing all positive results or were some negative and others positive? This is called “directedness” and can be translated into a grade.
The US Preventive Health system uses the following final “Grades” based on both the quality of evidence or proof and the risk versus the benefit of the treatment as follows:
- Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweighs the potential risks. Clinicians should discuss the service with eligible patients.
- Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients.
- Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations.
- Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.
- Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.
So now you know how “evidence” is really graded in the scientific community. Unfortunately a lot of this has not been applied to the natural health and natural remedy space. There are two problems. First of all, high level A evidence is not as readily available for natural health and remedies because the research is lacking. Secondly, natural remedies often depend on interaction within the herbal supplement for example. So, it is harder to establish a good cause effect relationship. Having said that, there is evidence and we try to find it where available. Visit our Cureology Information Centers on various health topics and natural remedies where we try to provide as much science based information as possible.