Expertise and Experience matter, & go hand in hand with a good understanding of evidence based medicine (EBM).

Experts and experienced physicians who dismiss EBM, and EBM proponents who dismiss expertise and experience are not helpful to the best interests of the patient.

Some of us who have been involved with EBM for a very long time (33 years for me) have come to recognize problems when its applied with evangelical fervor

@trishgreenhalgh, one of the pioneers of EBM, wrote about the survival of EBM during this pandemic. http://bostonreview.net/science-nature/trisha-greenhalgh-will-evidence-based-medicine-survive-covid-19

I had a conversation after 30 years with one of the people who introduced me to EBM 1987, & the writings of Sackett et al, Dr. Alan Gijsbers, who had similar comments to what @trishgreenhalgh wrote about.

I practice EBM. I develop investigator initiated diagnostic and prognostic testing, & conduct and complete investigator initiated randomized trials. I intend to continue to do so.

But only by doing these studies did I recognize how hard it is to do them, learn what’s feasible in & what’s not, & identify when waiting for evidence is against the best interest of the patient/public based on risk of the intervention vs risk of what we are preventing/treating.

I wrote a thread on the barriers we face to do investigator initiated RCTs in the US. Right now I have a trial that’s stuck after full approval by 50 experts for a year in a disagreement between FDA and NIH. https://twitter.com/vincentrk/status/1230248123148230656?s=21 https://twitter.com/vincentrk/status/1230248123148230656

It’s easy to say the convalescent plasma trial should have been a large randomized trial. But there is no Moderna behind a plasma RCT. It was designed at the start of a pandemic by docs wanting to save lives. It grew beyond their imagination. @DrMJoyner @ACasadevall1

It’s easy to say we need randomized trials. But public funding for investigator initiated RCTs are scant. Your own institution would not let you do an RCT without funding.

Also only by doing one can you recognize the number of people who have veto power over your perfect design

There is a difference between masks and vaccines. Between hand hygeine and hydroxychloroquine. It’s the difference between when an RCT is not needed versus where one is imperative.

In between there is a spectrum where decisions have to be made on risk benefit judgment calls.