-----Original Message-----
From: Adrian Freeman [mailto:[log in to unmask]]
Sent: Tuesday, May 07, 2002 12:21
To: Greener, Jenny
Subject: RE: How do various specialities view EBM?
This is the point where we have the challenge and excitment of practising
medicine. I am speaking as a UK GP. My focus is completely on the level of
the individual patient. For that patient I am balancing the evidence for a
particular service against their needs and wants. I have to help them to
interpret the evidence and more often than not the robustness of any
evidence for that individual patient sharing their health with me is poor. I
know that globally resouces should be husbanded to provide for example more
hip replacments. However the quality of life for that individual patient
could be enhanced considerably by public money paying for an intervention
with some evidence but not totally robust.
It is a wonderful challenge to use EBM appropriately. As a doctor I feel
uncomfortable refocussing away from the level of the individual patient. And
yet I know the needs of society, I know that evidence is based on a
scientific and robust methodology. I also know that the patient in front of
me might have been excluded from any robust trial because of their multiple
pathology, poor compliance and just being a struggling human being who could
not fit into a controlled and scientific research protocol.
By the way, I am too busy/lazy to find out, what is the evidence for
prescibing statins in a patient in their 80s with known ischaemic heart
disease, previous CVA, with residual paralysis and multi infarct dementia
resident in a nursing home with caring relatives who want everything to be
done for their mother? If the answer is no statins then start removing one
at a time each of the above descriptors.
Dr Adrian Freeman MMedSci, FRCGP
-----Original Message-----
From: Evidence based health (EBH) is the integration of individual
knowledge [mailto:[log in to unmask]]On Behalf Of
Greener, Jenny
Sent: Monday, May 06, 2002 01:24
To: [log in to unmask]
Subject: Re: How do various specialities view EBM?
How about refocussing the question away from the level of the individual
patient - if there is no robust evidence of effectiveness for a particular
service, should public money continue to pay for it?- perhaps a question of
particular relevance in the UK NHS context.
Jenny
-----Original Message-----
From: Stephen M. Perle, DC [mailto:[log in to unmask]]
Sent: Thursday, May 02, 2002 5:49 PM
To: [log in to unmask]
Subject: Re: How do various specialities view EBM?
Unfortunately you did not answer my question. I ask a genuine question and
your
response is flippant.. I know it is an anecdote, but if what I do is only
placebo, how do I rationalize experiences like the one related? Does it
seem
likely that this was a placebo response? Doesn't placebo response require
the
patient to believe that the placebo is or could be effective?
I understand what the literature tells us about the effectiveness of what I
do. I
know that at best it is equivocal and thus one must use their own judgment
when
confronted with a patient in pain. Isn't our current state of knowledge
when it
comes to the treatment of low back pain such that the evidence for any
treatment
is poor? So should I say to the patient, "You know research has not
definitively
found any treatment to help so suffer?"
Obviously, the anecdote (which I know holds no probative value to the world
of
science) is my experience, thus it colors my judgment and pushes me off the
fence
to decide that lacking more definitive research I shall continue to use my
best
judgment and treat patients with the tools at my disposal. I say instead to
the
patient let's try a trial course of treatment and see if you respond. Is
this
not what Sackett (1) means when they say EBM is the best available external
evidence, patient's desires and *doctor's expertise*? Or did I miss the
meaning
of doctor's expertise?
1. Sackett DL. Evidence-based medicine [editorial]. Spine
1998;23(10):1085-6.
preston wrote:
> Unfortunately you offer a typical response, nice anecdote!
>
> > I always tell my students that when you treat a patient and they feel
better
> > *after* they have left the office, they should always question was this
> > placebo or natural history. But when one sees instantaneous responses I
> > have less belief it is natural history but it could still be placebo.
> >
> > So from my personal experience let's look at a low back pain patient
where
> > the literature is much more equivocal. The patient barely walks into my
> > office. I mean they walk bent over with their hands on their thighs to
help
> > hold up their body. They are obviously in extreme distress They have
been
> > suffering for two weeks with no change in Sx. They saw their M.D. and
had
> > both Rx NSAIDs and muscle relaxers which have had absolutely no effect.
A
> > friend twists their arm and makes them come to see the quack, er I mean,
the
> > chiropractor. I examine the patient and give them one manipulative
thrust
> > and concurrent with the thrust they are instantly pain free. (BTW this
is
> > an example of a relatively common occurrence) If this is a placebo, why
> > didn't the medication work as a placebo? Why is the placebo a treatment
> > that they absolutely did not want because they knew it would not work?
> > Aren't placebo effective because the patient BELIEVES it will work?
--
_____________________________________________________________________
Stephen M. Perle, D.C.
Associate Professor of Clinical Sciences
University of Bridgeport College of Chiropractic
Bridgeport, CT 06601
www.bridgeport.edu/~perle
_____________________________________________________________________
Ignorance more frequently begets confidence than does knowledge:
it is those who know little, and not those who know much,
who so positively assert that this or that problem will never
be solved by science. Charles Darwin
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