October 9, 2009 | 8:13 pm
Posted by Albert Fuchs, M.D.
Around the turn of the last century medical practice was in a sorry state. Despite dramatic advances in physics, chemistry and physiology, the day-to-day practice of medicine was still entirely estranged from the scientific method. Medical training and medical practice was still what it had been for thousands of years – an apprenticeship in which treatments were passed down from teacher to student and applied by doctor to patient for generations without rigorous testing. At about that time leaders in medical education sought to bring the scientific rigor of other disciplines to medical education and medical practice. We can’t say that their work is complete. The rigorous testing of therapies in randomized trials and the deliberate attempt to base clinical practice on the results of those trials (what we now call evidence-based medicine) is only a few decades old. And even now, many physicians are deeply skeptical of evidence-based medicine, preferring to rely on their own experience or on traditionally accepted treatments.
I have no objection to relying on my experience or my judgment in the many cases for which scientific evidence is lacking. Every day doctors face clinical situations for which no large randomized trials provide data. That is the time for experience, improvisation, the art of medicine. But some physicians resist relying on science even in cases in which studies exist and are clear. They assert the importance of their autonomy and experience and refuse to follow “cookbook medicine”. The problem with that approach is that our experience frequently fools us. We remember best the cases that conform to our biases and expectations, and tend to forget the ones that challenge us. We overestimate the frequency of dramatic outcomes and underestimate the more common boring cases. We deceive ourselves to maintain our preconceptions. That’s why to get at the truth studies have to be blinded and randomized. The experience of every living person suggested that the sun revolved around the earth. It was only Galileo’s data that convinced him otherwise.
Though medicine has a long way to go, we’re moving in the right direction. But there’s another field which is now approaching the scientific revolution that medicine started a century ago – psychology. Much of clinical psychology remains the transmission from teacher to student of untested but long-used therapy methods. At the same time, the last few decades have seen remarkable progress in the science of mental illness and psychotherapy. A specific kind of psychotherapy called cognitive behavioral therapy has been proven in many studies to be helpful for many disorders, especially in the family of anxiety disorders. This scientific proof is startlingly lacking for many other forms of psychotherapy. But there is a schism between the scientific findings and the education and practice of psychology. Most psychologists have not been trained in cognitive behavioral therapy and most do not practice it, relying instead on unproven techniques.
This is not my criticism. It is the criticism of three psychologists led by Dr. Timothy Baker in the University of Wisconsin who authored an article in Psychological Science in the Public Interest. (See link below.) The article details the many evidence-based psychotherapy techniques available and then shows how infrequently these techniques are used in practice. The editorial that precedes the article is a clarion call for the field of psychology to reform itself if it is to continue serving patients.
I have the pleasure and honor to take care of several psychologists and have psychologists as friends. (I look forward to their emails about this.) My intention in this post is not to point fingers or criticize. It is to highlight an important positive development in psychology and to encourage psychologists to trust science.
Newsweek article: Ignoring the Evidence. Why do psychologists reject science?
LA Times Booster Shots: Do therapists know what they’re doing? Don’t bank on it, 3 psychologists say
Psychological Science in the Public Interest article: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care
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