Only the weak survive

Our rigid adherence to the Randomized Controlled Trial (RCT) as the only means of advancing knowledge in the realm of therapeutics is central to our collective lack of progress in the past several decades. At least inside the walls of the traditional health care system. 

Outside the walls of that system, the thoughtful application of scientifically-based lifestyle interventions – ones which are not amenable to evaluation by RCT –  has led to results that simply aren’t possible within the traditional system. Not surprisingly, confidence in that system continues to erode

The prototypical example here is the meteoric rise of the ketogenic diet. 

There’s plenty of noise, but the signal is clearly there – just as it does with epilepsy, nutritional ketosis provides benefits in other conditions (many of which involve the brain in some capacity) that surpass anything that can be accomplished with a prescription pad. 

Ketogenic diets were first used therapeutically for epilepsy in the early 20th century. For a century, then, all of those other transformative applications that we’ve only recently begun to discover were unknown. Not because we weren’t smart enough to find them, but because we weren’t allowed to ask the questions that would allow us to do so. 

The ketogenic diet is just one tiny example in a sea of opportunity, but it gives a glimpse of what’s possible once we escape from the RCT straightjacket.

At one end of the spectrum are interventions that are fixed, universal (“one size fits all”), and single factor. We’ve likely squeezed out most of the juice from these already (chiefly in the realm of infectious disease). Yet, these are the kinds most appropriate for the RCT.

At the other end are those that are flexible, individualized, and multi-factorial. We have no established, validated method of evaluating and advancing knowledge about interventions of this kind.   

In other words, at this time our system only allows for the evaluation and validation of the weakest, most dangerous kinds of interventions we have, while the potential of our strongest and safest ones goes largely unrealized.

The concept behind evidence-based medicine is sound. The only way to advance knowledge of what works in human health is to subject our efforts to scientific scrutiny.

Yet, strict adherence to evidence-based medicine, in its current form, means denying people the most powerful tools we have to improve human health.