As an CAM provider who practices EBM in spinal manipulation I have few if
any peers. CAM providers are not aware of EBM/guides and if they were it
appears from these posts they would not follow them anyway. Any thoughts as
to bringing EBM/guides to CAM providers?
--
Preston H. Long DC
> From: "Sontheimer, Daniel MD" <[log in to unmask]>
> Reply-To: "Sontheimer, Daniel MD" <[log in to unmask]>
> Date: Sat, 13 Jan 2001 10:15:17 -0500
> To: [log in to unmask]
> Subject: Re: demise
>
> 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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