Here is the EBM manifesto. It has appeared on my Twitter timeline so many times that I decided to read it. Here is what I found.Before I offer some comments, however, I would like to make it clear that I am focusing on the language of the document only. I do not and do not wish to comment on what the authors of the document thought, intended, hoped for. If anything, I want to show the document in line with (what I think are) the dominant discourses of medicine. The discourses that, perhaps, the medical profession might want to look at seriously some day.
Let me declare my hand. The EBM manifesto is a very powerful document. It assumes and exudes power. It crushes anything in its way.
1. The first thing that struck me about the manifesto is the ‘objectivity’ it tries to impose on me, the reader. Just look at the first two sentences:
There are huge shortcomings in the way that evidence based medicine operates today: bad quality research, evidence that is withheld, piecemeal dissemination, a failure to respect patients’ priorities, and more. There is also a long history of people, and organisations, trying to fix these problems.
Michael Halliday, the linguist in whose footsteps I clumsily shuffle along, talks about sentences starting with ‘there is/are’ in terms of existential processes. In other words, they are used to tell the addressees of existence of things. The shortcomings are just there, just as there is a history, no argument, it is simply stated in the linguistically most certain way: in the third person, no qualifications, no frills (or modality, for linguists). Indeed, the no-frills third person continues as we read that amount of research has grown, evidence has been accompanied, disquiet cannot be dismissed (even though, surely, disquiet hardly grows on trees), problems include, you name it, the document basically tells us how it is.
The power of the document lies in simply telling the reader what the (medical) reality is. There is no doubt, there is no perspective – the authors simply define, describe, diagnose and not even a shadow of a doubt creeps in. I am in awe, I wouldn’t presume.
Incidentally, you might wonder, of course, why people and/or organisations are rendered as ‘a history’, rather than as agents doing things. The answer is simple: it would ruin the objectivity of the existential process (it would ruin one other thing, but I will come to it later). There is no need (yes, I’m doing it, but sarcastically!) to introduce people into this. The document talks the world here, medicine is its oyster!
2. When I saw all this, I started looking for people in the document – surely, it can’t be only ‘the facts’. I particularly focused on pronouns (they are quite important for linguists like me). Quite surprisingly, I have found only two pronouns referring to people.
First, crucially, I found ‘we’, which appears an astonishing 14 times (another 2 for ‘our’) in the document! This is like a red light flashing furiously! Especially when you consider that the second pronoun I found, ‘you’, was used only once (yes, really!). Fine, another 3 for ‘your’. This is a document about ‘we’, ‘we’ is speaking and speaking explicitly. And the question which is almost automatic here is who is ‘we’, so, let’s consider it.
Well, ‘we’ appears as early as in the third sentence:
We want to pull together a clear set of achievable goals, and a strong overview of the strategies that work best, to help deliver change better, and faster.
There is nothing special about it, is there? It probably refers to the authors of the document. No problem, then? Mmm, almost. Because the next time ‘we’ appears is in the header:
Why we need better evidence for better healthcare
And the question who exactly is ‘we’ gets more complicated. It can refer to authors of the document, but, quite frankly, 6 (important) persons’ wishes to have better evidence are hardly something that should set the medical profession on fire. The question who ‘we’ is get more pressing, especially, when you take the next sentence with ‘we’:
we have a major structural problem with the current production and use of evidence
“We do?”, I’d like to ask immediately. So, am I perhaps part of the ‘we’? As the sentence is unlikely to refer only to the authors and ‘we’ now takes on a new identity and, to be honest I have no idea who the authors speak with (or ‘for’, if you like). So, do you hold hands with me, after all doesn’t this evidence stuff concern me a bit? I was already holding my breath, alas, the disappointment was swift and brutal. I read:
our flawed system generates evidence that has reached the wrong result, or conclusions that don’t matter to real world patient
Clearly it is ‘your system’ and I can only be a ‘real-world’ patient, well, with my degrees perhaps I can only aspire to be a ‘real-world’ patient. Having read this, I stopped even hoping that ‘we’ might possibly include me. I’m just a patient. Damn it! My father so wanted me to be a medic, like my grandfather. But then, I understand, evidence-based or not, at the end of the day, the patient can hardly be ‘we’ with the doctors, can they? Unfortunately, I don’t think I am very much part of the ‘you’ either. I need to face it, I’m on the margins and I am fed up with pronoun identities.
It’s not really necessary to explain how power works here, is it? The document so nicely puts a barrier between the medics and the patients that commenting on it would just be painful.
3. But let’s not be fussy about the (stupid) identity of ‘we’. Let’s consider what ‘we’ does. Here are only a few examples:
- we have set out
- we think
- we are running
- we will gather
- we hope
I mean, good for you. You clearly do all sorts of things, such an active, albeit pretty undefined, group of, let’s face it, powerful people who have the power to define reality. But even though I already know that I am not in the ‘we’, might I possibly have permission to do something? So, my hopes slightly up, I started looking at what I, the patient, can possibly do. Here are all instances of the word ‘patient*’:
- a failure to respect patients’ priorities
- real improvements in patient care
- failure to take account of the patient perspective
- conclusions that don’t matter to real world patients
- including above all patients
Bloody hell, I hardly expected fireworks, but, like, nothing?! I am reduced to a perspective? As you (personified by the powerful ‘we’) do all those things, in one manifesto you have stripped me off all my actions, agencies. Yes, yes, you want to ‘include me’, but have you noticed that I have no say in this? Including me means that you are actually doing something to me. And as it is apparently something good, I should now be (eternally?) grateful that a group of doctors decided to include me. Gosh, so mighty nice of you!
As you set, think, hope, gather and so many other things, I, this passive context of a perspective can only be included. Frankly, thanks, but no, thanks. You have crushed me enough and I don’t care much for a working relationship in which you decide ‘to include me’. But then, can we possibly imagine the possibility of me including you? That even sounds wrong!
Incidentally, do you remember the ‘history’ from the second sentence? Rendering those people as ‘doers’ would ruin reserving action and agency for the powerful ‘we’. The way it is phrased, it is only ‘we’ that does things and has the power to be an unfettered agent. Go medicine!
4. Now, to be honest, I am not in the least surprised by how the document has been written. It’s part of how powerful doctors speak (un)to us, patients. The document is part of a larger set of practices and cannot possibly be outside them. But in my final point I want to risk going outside language and say something about medicine also as a set of ideology-laden practices. Of course, from the point of medical research, I have practically no view as to what the authors put as the priorities for EBM. The problem is, however, that I think their priorities are (at least partly) as social as their document it.
And so, I want to say one more thing in reference to this point.
Reduce unwarranted variation, overdiagnosis and unnecessary medicalisation.
This is something I’ve been thinking about for some time. I want to make a point about social construction of false negatives and false positives. The point is based on my subjective experience, but I actually would like to do research on it, if someone would like to partner up.
When I go to see a doctor in my native Poland, the doctor is at pains to make sure that s/he does not miss an illness. They seem to be quite scared of false negatives. After all, if I come to see the doctor, there must be something wrong with me and the doctor’s role is to discover it. On a few occasions I actually left a doctor’s surgery with medication ‘just in case’ I would feel worse or the possible condition would develop. Better safe than sorry for Polish doctors, it seems, is that it’s better to err on the side of illness.
British medicine is the opposite. Doctors here seem to be scared of a false positive more than of anything else. You see a doctor and their favourite course of action is ‘paracetamol and much to drink’ and let’s wait. As Polish doctors are visited only by ill people, British doctors seem to think that their patients are these oversensitive wooses who just can’t wait a couple of days more in which they would discover that they are fine. Sometimes, I actually wonder about the nature of death in British medicine. If I die, at least there will be certainty I was actually ill. Phew, the antibiotics were actually necessary and the doctor didn’t contribute to the dreaded world antibiotic resistance. I have observed the above over many years and over the many a medical visit. Is it true? I don’t know, but when I mentioned it to a doctor recently, he looked quite distraught, as if I had discovered the cherished secret of British medicine. Seriously.
And so, when I saw that the EBM manifesto focuses on overdiagnosis, I smiled at myself. Absolutely – this is exactly what you would have written. That’s the in thing. But then as someone who was recently told, assured and promised to be completely healthy, only to end up in hospital a few days later, I’d rather you focused on underdiagnosis.