Perhaps all this debate if EBM affects patient outcomes is a bit misplaced.
There is an inherent value in the understanding the quality of our
knowledge, what we know and what we don't know, in the spirit of Socrates
"discovery of ignorance". Certainly no one is arguing that those practices
that are believed to be inferior should be offerred to our patients (even if
the ultimate proof is lacking). Taking cost/effectiveness argument to the
extreme, we may as well ask What is the pragmatic value of poetry or the
literature for that matter? This is not to say that we should not be
critically examining "everything"...It is just that acceptance of EBM should
not per se be linked to the proof of EBM affecting patients' outcomes (even
if conducting of such a study is feasible).
ben
Benjamin Djulbegovic, MD,PhD
Associate Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute
at the University of South Florida
Interdisciplinary Oncology Program
12902 Magnolia Drive
Tampa, FL 33612
Editor: Evidence-based Oncology
http://www.harcourt-international.com/journals/ebon/
e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/
phone:(813)979-7202
fax:(813)979-3071
--
-----Original Message-----
From: Paul Flynn [mailto:[log in to unmask]]
Sent: Sunday, June 03, 2001 2:42 PM
To: [log in to unmask]
Subject: Re: Is EBM effective?
Surely using patient outcomes is a far too complex end-point for a study of
the effectiveness of EBM? Given that we know from our critical appraisals
that certain interventions are effective, then a suitable end-point should
be the proportion of interventions which are evidence-based. Baseline
studies have been done in most of the major specialties already. Obviously
given the gaps in evidence, the proportion will never be 100%.
One problem would be the nature of the control group. Doctors may seek to
update themselves and cannot be isolated from the various EB edicts from
their relevant Royal College and suchlike. Given that the background use of
EB principles is likely to rise anyway, the intervention arm will have to be
very intensive to produce a measurable difference.
I don't think it will ever happen.
Paul.
--
Mr Paul M Flynn MRCOG
Consultant Obstetrician & Gynaecologist, Newcastle upon Tyne, UK
+44 (0)191 2825865; Fax: +44 (0)7092 173892; Pager: +44(0)7669 175704
> Phil . Hall wrote:
>
>> I believe that you are referring to an article under that or
>> a very similar title by Dr. Geoff Norman at McMaster
>> University, published I believe in the mid '90's.
>
> Unless I'm mistaken, I believe the SR Drs. Gutherie and Sontheimer were
> referring to was the one by Chris Hyde et.al. funded by the UK National
R&D
> Programme released August 2000. It is the most comprehensive SR on the
> effectiveness of teaching critical appraisal (CA) to date and shows CA
> teaching improved knowledege of and attitude towards CA, weakly improved
CA
> skills and may have increased journal article reading. All outcomes were
> short term (less than 12 months). No studies examined the effect of CA
> teaching on patient outcomes, self learning behaviors, clinical decision
> making or learner satisfaction, arguably the only "important" outcomes;
the
> others being surrogate markers of uncertain validity.
>
> Ken
>
> NH Jacksonville
> Department of Family Practice
> (904) 777-7963 dsn 942
>
> -----Original Message-----
> From: Philip Hall [mailto:[log in to unmask]]
> Sent: Friday, June 01, 2001 10:32 AM
> To: [log in to unmask]
> Subject: Reply: Is EBM effective?
>
>
>> June 1 2001 ("rabbits!")
>>
>> I believe that you are referring to an article under that or
>> a very similar title by Dr. Geoff Norman at McMaster
>> University, published I believe in the mid '90's.
>>
>> I agree that EBM use, teaching of its use, and adoption of
>> its methods are not the same thing as achieving longer or
>> better quality of life (subject to the definition of the
>> latter). There is excellent evidence from Kahneman, Tversky
>> and others that human decision making given uncertainty is
>> irrational, and lots of evidence elsewhere that unsupportable
>> but habitual interventions persist, and that effective ones
>> are adopted slowly at best.
>>
>> There are other relevant questions as well that have not been
>> addressed in evaluating the EBM effect, whatever it is. One
>> is whether the appropriate outcome measures have been sought.
>> Another is whether they have been sought for long enough. The
>> list goes on.
>>
>> Perhaps the human species has become relatively resistent to
>> ineffective interventions, and somehow survives despite most
>> of them. Someone - I would love to know who - said "Life is
>> too short to drink bad wine." Perhaps critical appraisal, or
>> as Norman once called it "CRAPP DETECTION" and EBM are
>> methods to assess whether the wine is good or bad, before drinking it.
>>
>> Sincerely,
>> Phil . Hall
>> Maternal & Fetal Medicine
>> University of Manitoba
>> Winnipeg, Manitoba, Canada
>>
>>>>> My take on this SR was that is why this list has been
>> relatively quiet, of
>> late. Two years ago, when I joined, there would at least be
>> 2-3 posts per
>> day. Now the volume appears less to me. I have no doubt
>> right now that all
>> we can say about EBM is that it can make practices more
>> evidence-based.
>> Helping patients live longer or with better quality of life
>> is an entirely
>> different matter. I remember seeing an excellent article
>> (but now have
>> lost the reference) titled something like "A Critical
>> Appraisal of Critical
>> Appraisal". It wasn't kind to EBM, and really spoke to the
>> need for the
>> questions brought up by these posts.
>>
>> I think EBM is good, even if all it does is make practice more
>> evidence-based. I think patients deserve therapies that have some
>> foundation, as opposed to tradition or whimsy. I think this
>> is why we will
>> see EBM evolve along with reflective practice to create an
>> environment,
>> where science and art can compliment one another.
>>
>> Dan Sontheimer
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