Thanks, I have enjoyed your work Family practice and BMJ. I hope we can
move EBM towards an implementation and practice level, instead of the
current trend I call "appraisal for appraisal's sake", that gives little
regard to utility and applicability.
Keep thinking!
Best Regards,
Dan Sontheimer
Assoc. Director
Spartanburg Family Medicine Residency
Spartanburg, SC USA
> -----Original Message-----
> From: Toby Lipman [SMTP:[log in to unmask]]
> Sent: Saturday, January 13, 2001 5:35 AM
> To: Sontheimer, Daniel MD
> Cc: [log in to unmask]
> Subject: Re: demise
>
> In message <CF1AA81579F2D211B64600805FFE91E102383C32@prc23nts>,
> Sontheimer, Daniel MD <[log in to unmask]> writes
> >Agreed, I think EBM next phase is to grow to a level, where it is used as
> a
> >lens/filter with which to guide the practice of Medicine.
> >Combining the work of EBM with reflective practice (clinical jazz in
> >Slawson's and Shaughnessy's work), can help move us forward.
> >
> >The biggest problem with EBM is the attempts to represent "the truth", as
> >being solelly defined by EBM. Thus, you now have drug reps, and other
> >soliciters approaching everything with "evidence-based" perspective.
> >
> >Perhaps there is a more post-modern perpsective for EBM, I think it is
> in
> >combining with reflective practice, and then we can avoid this bouncing
> >around of "the truth"
> >Dan
> >
> >
> You are right. I think the first phase of EBM was the working out of how
> research findings could be applied to clinical practice using
> epidemiological principle, and the realisation that clinicians had both
> the right and duty to question established practice.
>
> It has now (in the UK at any rate) been largely hi-jacked by expert
> groups who have adopted it as a sort of mantra to justify and give more
> weight to decisions they would have made anyway (see the recent
> controversy in the BMJ and rapid responses about the National Institute
> of Clinical Excellence (NICE)).
>
> While there is a minority grassroots movement that is attempting to
> encourage evidence-based practice by coal-face clinicians and managers
> (such as, for example, through the London, Oxford and our own Durham
> workshops) there is not nuch widespread support at senior levels for
> ordinary clinicians to acquire these skills - they would rather keep
> them to themselves (although as the NICE imbroglio shows, not
> necessarily with any great degree of competence). This may well be
> because senior clinicians and managers, in their hearts, don't really
> want more junior people to be able to make their own decisions according
> to the evidence and their patients' needs, because it threatens the
> establishment's power and influence (see Lipman, T. Power and influence
> in clinical effectiveness and evidence-based medicine. Family Practice
> 2000;17:557-563).
>
> The other major issue is: once you have learned the skills of EBM, how
> do you actually use it in clinical practice? Some work has been done on
> ways of accessing evidence quickly in the clinical setting (eg the
> 'evidence cart' work). Most UK GPs now have internet access at their
> desks and some are beginning to make tentative experiments on including
> the EBM process within the context of routine consultations. It is
> becoming clear to me that this is a huge field for research, and that
> EBM has to be integrated into an already sophisticated consultation
> process rather than replace it with something quite different.
>
> So we need to ask: is it feasible? how much time do we need? what
> prompts us to ask questions and do searches, given that we are never
> going to have the time (nor do we need) to do this in every case? how do
> we involve the patient in this process? how do we judge the extent to
> which patients want to share decision making? do common scenarios such
> as sore throats (in which we will soon know the evidence by heart!) lead
> us to develop "EBM scripts", in which the scenario is learnt and acted
> out repeatedly?
>
> And so on.
>
> So I think we are beginning to understand that learning the basics of
> EBM is only the beginning and that we are entering upon a time in which
> we have to discover the way it can be used and what impact it will have
> upon practice. Maybe that is why we haven't been so vocal recently - we
> are thinking!
>
> Toby
> --
> Toby Lipman
> General practitioner, Newcastle upon Tyne
> Northern and Yorkshire research training fellow
>
> Tel 0191-2811060 (home), 0191-2437000 (surgery)
>
> Northern and Yorkshire Evidence-Based Practice Workshops
>
> http://www.eb-practice.fsnet.co.uk/
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