Bruce Guthrie posted:
> Roy Poses and Daniel Sondheimer wrote:
>
> > I don't think EBM is its own foundation. I think the foundation of
> > EBM is the notion that applying logical reasoning and the best
> > scientific evidence ought to produce optimal results in medicine and
> > health care. This further rests on the assumption that the scientific
> > method is the best way to find the best approximation of the truth,
> > and further, of course, that there is some sort of external truth or
> > external reality.
>
> EBM certainly isn't its own foundation since as far as I'm aware
> there is little evidence that practicing EBM improves patient
> outcomes. The evidence I'm aware of is relatively weak - I think it
> would allow a weak B grade, or a C grade recommendation that
> people practice EBM. So obviously, its foundation must be an
> appeal to some idea of science or logic. The difficulty is in
> deciding why this should mean that we practice EBM and not the
> 'old way' of trying to predict what will 'work' in clinical practice on
> the basis of physiological or other basic science principles. The
> old way uses exactly the same appeal to science or logic but,
> using the method we call EBM, we can show it to be unreliable.
>
> I think Roy sets up his own false dichotomy by trying to force a
> choice between a belief in an objective reality and collection of
> objective data on the one hand, and an incoherent mumbo jumbo
> called non science on the other. Effectively, it consigns anyone
> who questions an objective reality to the outer darkness of
> superstition...
Brings to mind two cliches. First, "Data unites, theories divide." Just as
the Hawthorne Effect and Heisenberg Uncertainty Principle are recognized in
other fields, epidemiology recognizes that data can be objective
measurements within defined limits of precision, accuracy, and reliability.
Our differing interpretations, tempered by individual beliefs and values,
then lead to healthy debate and empirical research under a scientific
framework. Postmodernism's acceptance of every belief or value seems to
favor accepting every interpretation (perhaps the noise around true signals)
rather than favoring empirical processes of inquery to discern the
interpretations most consistent from a set of investigations (to discover a
robust theory, the signal under the noise). Second, epidemiology can ensure
fewer incorrect decisions, not necessarily more correct ones. How we measure
"improving patient outcomes" as an outcome of practice patterns matters.
Perhaps fewer adverse misadventures rather than marked overall improvement
(essentially, reducing variance more than reducing means) would be the more
appropriate measure of EBM's impact?
David Birnbaum, PhD, MPH
Clinical Assistant Professor
Dept. of Health Care & Epidemiology
University of British Columbia, Canada
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