EBM deals with this by saying ‘there is no viable alternative’, a remarkable statement of epistemological nihilism that enables much low quality snd pointless research.
(I’m sure this varies by jurisdiction too; I have only heard bad thing about US IRBs)
Some recent examples of problems with clinical trials:
1. Using a harmful or deliberately inadequate placebo. https://academic.oup.com/jnci/article/104/4/273/979399 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.0... https://pubmed.ncbi.nlm.nih.gov/34688044/
2. Starting a bunch of clinical trials using a biomarker which turned out to be invalid. https://www.nejm.org/doi/10.1056/NEJMoa1214271
3. Endless 'me-too' trials driven by pharma, with a low chance of success. https://www.statnews.com/2019/09/04/me-too-drugs-cancer-clin...
Source: My dad is a physician and I am an economics PhD who knows a lot of statistics and talks with him about these things.
A double blind placebo trial is the gold standard for testing causality. We don't have to go that far. We can use a hybrid of intuition and correlational tests, we can maybe sometimes not always need a placebo. The point is the causal test comes with a lot of technical challenges and we have options for other tests that are less challenging.
There is a spectrum of correctness and rigor for science and we should know when to utilize something extremely rigorous or less rigorous. The barbaric practices you describe only come from an lack of awareness of what statistical rigor and science is.
We need to move medicine beyond the abilities of a single individual.
As a physician you are likely aware, but for anyone reading who isn’t: this paper is from the Christmas issue of the BMJ, which publishes “joke” studies. It’s not really meant to be taken seriously in any way.
Nonsense, of course. But then there's a lot of randomized, controlled trials out there that are just as flawed, only in ways that are non-obvious to non-physicians, or even physicians with different specialities. "Study X proved Y" is never as straightforward as it seems to the lay public.
Yes, absolutely, medicine should be evidence based. Yes, large randomized, double blind, placebo controlled studies provide a lot of information.
However, there are limitations with these kinds of studies.
First, it may not be ethical or practical to study some things in this manner. For example, antibiotics for bacterial pneumonia has not had a randomized, double blind, placebo controlled study.
Famously, there was an article discussing how parachutes in jumping out of airplanes had not been subject to a randomized, double blind, placebo controlled study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/
Later, somebody did that study: https://www.bmj.com/content/363/bmj.k5094 and found that parachutes made no difference, but it is not applicable to any real world case where you would use a parachute.
Which illustrates the second issue with evidence based medicine. Many times, the large trials's main thing they are measuring are different than what you really want to know, or the population they studied has significant differences from the patient who is right in front of you. How to apply the results of the large study to the individual patient in front of you is still more of an art than a science.
Finally, I think there is the example from machine learning. It has turned out that instead of creating more and more rules, feeding lots and lots of data to a neural network ends up performing better in a lot of machine learning cases. In a similar way, an experienced physician who has treated thousands of patients over decades has a lot of implicit knowledge and patterns stored in their (human) neural networks. Yes, these decisions should be informed by the results of trials, but they should not be discounted, which I think that Evidence Based Medicine did in at least a small part. During my residency, I worked with physicians who would examine and talk with a patient and tell me that something is not right and to do more extensive tests which would end up unearthing a hidden infection or other problem that we were able to treat before it caused major problems. They were seeing subtle patterns from decades of experience that might not even be fully captured in the patient's chart, much less a clinical trial without thousands of participants.
So yes, these clinical trials are a very important base for knowledge. But so is physician judgment and experience.
Source: I am a physician.