I would like to pick up on the general issues raised by Adrian Roberts:
> How should we deal with such a major disagreement between experts, as is
currently revealed in the mammography debate?
Deal with it just as it : evidence is to be interpreted and there are bound
to be differences in interpretation. Debate is constructive.
> EBM claims to provide ordinary doctors with the ability to be able to
> critically appraise evidence; to sort the wheat from the chaff. What hope
> have they of accomplishing this when the professional epidemiologist and
> trialist appear unable to reach agreed and consistent conclusions?
The emphasis is on ability - not the provision of ready answers or
universally accepted conclusions. EBP should equip ordinary doctors (and
surely other health care professionals and managers?) with the ability to
follow the debate rather than expect the experts to give them the answers.
> ............what about the main concern, mortality? On the basis of the
Swedish studies there seemed to be sufficient certainty, just a few years
ago, that mammography conferred a 25% approx. reduction in mortality.
Does this not demonstrate that EBP is about constantly re-appraising
evidence? (BTW, even when the Swedish studies first came out, there were
voices of dissent).
>
> Will that wash with a sceptical audience at an
> introductory EB Health Care workshop? If the evidence based
> recommendations of "experts" can perform such a dramatic a U-turn on the
> value of mammography, how can we trust the "concrete" evidence on
> cholesterol lowering in secondary prevention of CHD, tight glycaemic and
> BP control in diabetes, or anything else, they might well ask?
>
What is the audience sceptical of? The idea of trials? If so, is there a
better way of finding out what advice to give to women about screening
mammography? (This is a real question - before the trials, private
organisations were offering private screening -on women under 50 too). Or
are they sceptical of systematic reviews? If so, is there a better way to
look at all the evidence? (We can think of examples of what happens when
only some of the evidence is selectively considered, either consciously or
unconsciously). Or are they sceptical of experts? Not a bad thing! It is
worth recalling that recommendations never follow automatically from
evidence - they are created by humans and there are many social influences
on the ultimate decision.
--
Kev (Kevork) Hopayian
GP, The Surgery, Main St, Leiston, Suffolk, IP16 4ES, England
Tel +44 (0)1728 830526
Fax +44 (0)1728 832029
www.suffolk-mag.ac.uk/kevhop
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