Anna, Nikki, Jason,

Good points!  Anna, I especially enjoyed the article - its great!. However, 
we can't be naive about EBP. It will do exactly that - control what we can 
and cannot do, or get paid for. As we all agree, it should not be the sole 
justification for therapeutic intervention. Who knows what this movement 
will create. Have a good day!

Rege



At 06:03 AM 2/6/2003 +1100, you wrote:
>Hello,
>
>I have been following the discussion with great interest. I have my views
>about those who are blinkered in thinking RCTs are the only solution to the
>profession's survival, credibility, efficacy, attraction etc etc.
>
>I thought this little article I found in the BMJ might give some of you a
>chuckle after this seeeeeerious discussion!
>
>if the photos don't come out on your screen, it would be worth getting the
>original and having a look, they are a lot of fun
>
>For those of you whose English is not their first language, the Macquarie
>Dictionary defines crap (a colloquial term) as [noun] 1. excrement;
>2.nonsense, rubbish; 3. junk, odds and ends; [verb] 4. to make a mess of,
>bungle;  5.annoy, disgust; 6. to defecate;  7. to talk nonsense (crap on);
>8. to fail (crap out)
>BMJ 2002;325:1496-1498 ( 21 December )
>
>
>
>EBM: unmasking the ugly truth
>Clinicians for the Restoration of Autonomous Practice (CRAP) Writing Group.
>
>Correspondence to: CRAP Writing Group, Poste Restante, London WC1H 9JR
>
>One morning we found a strange notice nailed to the door of the BMJ. On
>checking their email, all BMJ staff found the full, illustrated version of
>this report
>
>Clinicians for the Restoration of Autonomous Practice (CRAP) has written
>this report and nailed it to the door of the BMJ. We have done this
>anonymously and under cover of darkness to protect ourselves from
>retaliation from grand inquisitors in the new religion of Evidence Based
>Medicine (EBM). Our report is based on documents liberated by undercover
>agents who have successfully infiltrated the EBM movement to uncover the
>truth about EBM, its hidden agenda, and the shadowy forces behind it.
>Despite repeated denials by the high priests of EBM that they have not
>founded a new religion, our report provides irrefutable proof that EBM is,
>indeed, a full-blown religious movement, complete with a priesthood,
>catechisms, a liturgy, religious symbols, and sacraments. We can confirm
>that proselytisation is now occurring on a global scale and threatens the
>very existence of for profit, doctor centred, authoritarian medicine as we
>know it. CRAP has issued this rallying call to all who wish to conserve our
>traditional values.
>
>
>             10 commandments
>
>CRAP has long suspected that EBM secretly espouses cookbook medicine, based
>on a blind faith in "methodology," the alchemistic philosophical basis for
>this religion. We can now confirm the existence of an EBM bible and
>catechisms, which were discovered by chance when one of our members removed
>the mini CD Rom from a recently published EBM textbook and played it
>backwards. The 10 commandments of EBM, which were reportedly delivered as a
>printout to a prophet on Mount Hamilton, were presented against a musical
>background ("All you need is trials"):
>
>   a.. Thou shalt treat all patients according to the EBM cookbook, without
>concern for local circumstances, patients' preferences, or clinical judgment
>   b.. Thou shalt honour thy computerised evidence based decision support
>software, humbly entering the information that it requires and faithfully
>adhering to its commands
>   c.. Thou shalt put heathen basic scientists to the rack until they repent
>and promise henceforth to randomise all mice, materials, and molecules in
>their experiments
>   d.. Thou shalt neither publish nor read any case reports, and punish those
>who blaspheme by uttering personal experiences
>   e.. Thou shalt banish the unbelievers who partake in qualitative research,
>and force them to live among basic scientists and other heathens
>   f.. Thou shalt defrock any clinician found treating a patient without
>reference to all research published more than 45 minutes before a
>consultation
>   g.. Thou shalt reward with a bounty any medical student who denounces
>specialists who use expressions such as "in my experience"
>   h.. Thou shalt ensure that all patients are seen by research librarians,
>and that physicians are assigned to handsearching ancient medical journals
>   i.. Thou shalt force to take mandatory retirement all clinical experts
>within a maximum of 10 days of their being declared experts
>   j.. Thou shalt outlaw contraception to ensure that there are adequate
>numbers of patients to randomise.
>
>
>
>
>
>
>            Fig 1.   The Cochrane symbol, seen here in plans for the façade
>of the Cochranite Vatican that is to be built in Summertown
>
>
>
>
>
>
>
>
>Much of what is written in the EBM religious tracts can also be found as
>catechetical instruction in seemingly innocuous sources, such as the
>Cochrane Handbook and the CONSORT statement.
>
>
>
>        Religious symbols of EBM
>
>Symbolism within the EBM religion has developed rapidly. This may be due to
>the fact that the religion is actually all "old hat," as some brave critics
>have pointed out. Many symbols have been stolen shamelessly from other
>religions. The EBM cube, for example, was stolen from the Rubricons, and the
>Cochrane logo that appears not only in print but also as "crop circles"
>across the countryside seems likely to have been based on an ancient
>pharaonic pictograph (see fig 1).
>
>One of the most frightening discoveries by CRAP agents is a modern form of
>trepanation, in which EBM cubes are inserted in the heads of medical
>students (fig 2).
>
>
>
>
>
>
>
>            Fig 2.   Skulls of medical students showing circular incisions of
>trepanation used to insert EBM cubes
>
>
>
>
>
>
>
>
>       EBM liturgy and sacraments
>
>       The many forms of liturgy and sacrament that we have discovered
>include:
>
>         a.. EBM workshops, where the catechisms of EBM are chanted and
>novices are taught the tenets of EBM
>         b.. An annual pilgrimage to the Cochrane Colloquium, during which
>EBM devotees go without sleep for four days, speak in tongues, and
>participate in ritual ceremonies
>         c.. A bizarre ritual in which structured abstracts are placed in the
>gaping mouths of EBM devotees
>         d.. The bestowment of holy orders upon those who go on to become
>Tutors, Convenors, and Coordinators
>         e.. Anointment of the sick with evidence at the bedside (fig 3)
>         f.. A pilgrimage by truly devoted adherents to the religion, who
>travel thousands of miles to be initiated using total immersion in Coote's
>Paradise, at the western extreme of Lake Ontario
>         g.. A finger that is believed to be a holy relic. Adherents are
>divided as to the origin of the finger. One faction believes it came from
>Gordon Guyatt, and another believes that it came from Drummond Rennie.
>
>
>
>
>
>
>
>
>            Fig 3.   An EBM priest anointing a patient with evidence at the
>bedside
>
>
>
>
>
>
>
>
>
>        Proselytisation and excommunication
>
>EBM shares with many other religions an aggressive proselytisation. New
>members are recruited to the religion through workshops, colloquiums,
>religious tracts, and other publications. Although EBM does not yet have its
>own television channels, the internet is gradually being taken over by EBM
>sites. A recent Google search (10 December 2002) revealed 1 240 000 EBM
>sites.
>
>Like other religions, EBM is quick to excommunicate those who do not adhere
>to its tenets or who challenge the authority of the chief druids. Because of
>the fear of losing its following to the drug industry, EBMers who take jobs
>in industry are excommunicated. They may also be banished to live with
>unbelievers and those who adhere to other religious creeds in New Haven or
>at the New England Journal of Medicine, which are being transformed into
>modern day EBM Lubyankas. Other punishable offences include failure to
>publish the results of a trial and failure to report the results of a new
>trial in the context of an up to date systematic review.
>
>
>
>        The priesthood and EBM signs and symbols
>
>We are able to publish a photo of three EBM druids dressed in their
>vestments (fig 4). Note the socks, the shirts, and the sign they are making
>with their hands. EBMers are easily recognised by their white socks. The
>shirts seen in the photograph are worn at all times and never washed, but
>are normally hidden underneath other clothing. The secret sign they are
>making with their hands is used to identify themselves to each other, the
>three fingers forming an "E" for evidence. EBMers are known to provide
>mutual assistance and promotion within their secret order, sometimes using a
>specific EBM vocabulary, including words such as "trohoc," and passwords
>such as "allocation concealment" and "RCT," the last of which is used as a
>title of reverence in place of the ineffable (randomised controlled trial).
>
>
>
>
>
>
>
>            Fig 4.   Three EBM druids dressed in their vestments
>
>
>
>
>
>Governments around the world are rejoicing in the growth of the EBM religion
>because it makes it easier to withhold or withdraw support from all forms of
>care for which there is deemed to be insufficient evidence. Meanwhile, the
>drug industry is secretly assembling a massive fighting fund to protect
>endangered drugs from the inroads being made by EBM. As a consequence of the
>unbridled success of EBM, it is anticipated that nearly all surgical units,
>public health departments, and paediatricians will be forced to close shop
>because of a lack of randomised evidence supporting their activities.
>
>
>             Factions and a glimmer of hope for the future
>
>As in most other religions, factions are beginning to emerge within EBM, and
>CRAP sees a glimmer of hope in these developments. EBM currently comprises
>four major denominations:
>
>
>       Dire consequences of EBM
>
>       In addition to uncovering EBM religious tracts we have discovered top
>secret plans that confirm and go beyond our deepest fears about EBM's
>intentions to take over the world:
>
>         a.. The BMJ, already in the thrall of EBMers, will take over all
>other medical journals, using a combination of spamming and viruses to
>attack their websites
>         b.. The National Health Service will become the National Evidence
>Service, with 80% of the time of all employees devoted to generating,
>meta-analysing, and critically appraising evidence
>         c.. An upper limit will be placed on the IQ of all students admitted
>to medical school
>         d.. Drug companies will be required by law to reveal all of their
>evidence. As a result of this it is expected that by the year 2020 the last
>of the 10 drug firms still in existence, following multiple mergers, will
>close its doors due to the loss of the right to hold proprietary secrets
>         e.. NICE (the National Institute for Clinical Effectiveness) will
>take its gloves off and change its name to NASTY (National Academy of
>Stingy, Therapoclastic, Nihilistic Yobs)
>         f.. The Nobel Prize for medicine will be subverted. In the future it
>will be awarded to large collaborative endeavours, rather than to
>individuals. It will be given solely for methodological research into the
>intricacies of randomised trials and systematic reviews
>         g.. In future among doctors, only EBMers will be awarded
>knighthoods, at one of three levels (Level 1, Level 2, and Level 3).
>
>
>   a.. Cochranitesmembers of a worldwide order that has Archie Cochrane as
>its patron saint. They worship systematic reviews
>   b.. Meta-anophilesa heretical spin off of the Cochranites, who believe in
>combining the results of all the randomised controlled trials in the
>universe. Their current estimate of the ultimate summary statistic is 42
>(95% confidence intervals 41.9999 to 42.0001)
>   c.. PharmacoidsEBMers who work for the drug industry, sometimes secretly
>funded. This faction was started by industry, which initially believed that
>EBM would ensure continuation of their obscenely high profit margins,
>because most randomised evidence concerns drugs. Many in industry now regret
>this initiative due to the aggressiveness of the Cochranites and the
>Meta-anophiles, who now demand that industry divulges all of its secret
>evidence, instead of publishing only the evidence that favours its products
>   d.. Simplefolkmembers of a much smaller order that worships large, simple
>randomised controlled trials. Adherents want to make large simple trials
>mandatory for all treatments, restrict the number of outcome measures to a
>maximum of two, and allow only priests with a license to do subgroup
>analyses.
>In the end, EBM may destroy itself, just as many other religions seem to be
>doing. However, CRAP will not sit by idly. We have plans to take EBM to
>court in The Hague for crimes against humanity. Our case is based on
>challenging EBMers to provide proof, based on a mega-RCT or a meta-analysis
>of RCTs, that EBM does more good than harm. Where is the evidence?! It is
>time for unbelievers and those of other faiths to get tough and put a stop
>to the veneration of research evidence about the effects of health care. We
>must protect our unalienable right to exercise clinical autonomy, so that we
>can continue to do what we damn well please.
>
>       Acknowledgments
>
>Contributors: All authors contributed equally and all will act as
>guarantors.
>
>       Footnotes
>
>Funding: None.
>
>Competing interests: Lots (see bmj.com).
>
>
>
>Cheers,
>
>  Anna.
>
>
>Anna Lee
>Principal,
>Work Ready Industrial Athlete Centre
>
>Write to me at: [log in to unmask]
>
>Visit me at: www.workready.com.au
>
>Snail mail:
>Suite 3, 82 Enmore Road,
>Newtown  NSW  Australia 2042
>Australia
>
>Phone: (612) 95197436
>Fax:  (612) 95197439
>Mob: 0412 33 43 98
>
>----- Original Message -----
>From: "Patrick Zerr" <[log in to unmask]>
>To: <[log in to unmask]>
>Sent: Thursday, February 06, 2003 3:57 AM
>Subject: Re: evidence based practice
>
>
> > I would have to agree.
> >
> > To think that PT treatments, especially manual techniques, are similar to
> > prescribing x number of mg of penicillin is not the same type of RCT.
> >
> > There should be more focus on how we identify the differences in treatment
> > and patient activity.  Because what we do is so dependent on what the
> > patient does after they leave the clinic it's not accurate to say that the
> > treatment has or has not been effective without knowing all the details.
> > Until we can control for those details it will be difficult at best to
> > examine the effectiveness of our treatments.
> >
> > Patrick Zerr
> > www.apluspt.com
> > The easiest way to prepare for the National PT Exam!
> > www.summitpt.com
> > Summit Physical Therapy; Tempe, Arizona
> > ----- Original Message -----
> > From: "Regis Turocy" <[log in to unmask]>
> > To: <[log in to unmask]>
> > Sent: Wednesday, February 05, 2003 7:37 AM
> > Subject: Re: evidence based practice
> >
> >
> > > Colleagues,
> > >
> > >   Who decreed that evidence based practice will save the profession. I
> > > personnally belief, that if EBP is the only criteria we are going to
>"hang
> > > our hat on" it will be the DEATH of our profession. There are too many
> > > unquantifiable factors involved in our various therapeutic approaches
>and
> > > the therapist-patient relationship. To use one approach (EBP) as our
>only
> > > criteria is extremely short sighted. I think it is just one of the many
> > > factors that should be included in the equation. As you can probably
> > > summarize, I am not that anxious to "jump on" the EBP bandwagon. I would
> > > rather look at the millions of Americans who are "flocking" to
>alternative
> > > care clinics, who are getting better, after failing to do so with
> > > traditional medicine and physical therapy(in spite of EBP) and ask WHY?
>I,
> > > like many of you, have a long clinical history and cannot ignore all
>those
> > > other factors that have resulted in a very successful therapeutic
>outcome.
> > >  From my perspective it is time we take the "empirical blinders " off.
> > Just
> > > a thought!!
> > >
> > > Rege
> > >
> > >
> > > At 10:42 AM 2/5/2003 +0200, you wrote:
> > > >I think Frank Conijn has made an important suggestion in his message of
>3
> > > >February. Namely: 'We have to work on saving our profession. But we can
> > only
> > > >do that with <valid!>, in the absence of validat<ed> arguments'.
> > > >
> > > >It is clear that such arguments can only be obtained via due research.
> > > >However it is my personal impression that current PT researches
>worldwide
> > > >are mostly isolated and poorly coordinated (if coordinated at all). As
> > far
> > > >as I know, PT investigations have mainly been carried out at medical
> > > >universities which may have their own local/specific interests, biases,
> > and
> > > >priorities, which not always take into account the higher goals of our
> > > >profession. In addition, it seems that the teaching activity of
> > university
> > > >researchers has taken too much their time.
> > > >
> > > >In my opinion, we could consider an establishment of a global PT
>research
> > > >network dedicated exclusively to searching for those arguments Frank
> > > >mentioned. Small informal groups of researchers or even separate
> > individuals
> > > >(e.g. supported with appropriate grants) could also be included into
>such
> > a
> > > >network. Of course, it would hugely be welcome to coordinate these
> > > >researchers' investigations conducted in various countries (i.e.
> > conducted
> > > >using a multi-central design). I think a possible bureaucratic manner
>of
> > > >such coordination will be minimized if we'll find several respectable
>PT
> > > >researchers worldwide who will rather be more interested in scientific
> > > >soundness of our profession than in their remunerations appropriate. I
>do
> > > >not know whether the World Confederation for Physical Therapy has its
> > > >Research Department. If yes, then we surely could use their experience
> > and
> > > >potentialities. If no, then we could use their successful experience as
> > to
> > > >effective organizing the PT practice and adapt it, to some extent, to
> > > >coordination of our research efforts worldwide.
> > > >
> > > >Money? For the moment, I do not know from where. I am very far from
> > > >answering this question. Especially when sitting in this
>'restructuring'
> > > >country. Maybe PT equipment companies... Maybe grant-giving
>organizations
> > > >(why not The Wellcome Trust, the most serious and powerful biomedical
> > > >sponsor
> > > >over the globe?).. Maybe appropriate State Departments charged with
> > > >improving the quality of health care... Maybe all the listed in
> > > >conjunction...
> > > >I hope somebody from my colleagues abroad will be more productive in
> > > >economic assessing such a project and advising relevant sources of
> > funding
> > > >worldwide. Let's think together. And create, anyhow, something like an
> > > >'International Confederation for Physical Therapy Researchers'. Or
>'World
> > > >Physical Therapy Research Institute' (even virtual, not formal).
> > > >
> > > >In order to the validity of future results obtained by researchers of
> > such a
> > > >network cannot then be called in question by empowered persons and
>other
> > > >people, we should accordingly select those researchers taking into
> > account
> > > >their scientific degrees, professional honours, etc, which have
>currently
> > > >been recognized in most countries.
> > > >
> > > >I am confident of extreme necessity of urgent enhancing the level of
> > today's
> > > >PT research, and launching high-quality investigations into the
> > mechanisms
> > > >of influence of main PT agents and interventions. On the other hand, I
>am
> > > >sure that only sincerely devoted to Physical Therapy researchers from
> > > >various countries whose efforts have delicately been coordinated by
>their
> > > >senior colleagues - informal consultants/coordinators - are able to
> > provide
> > > >us with the arguments Frank mentioned.
> > > >
> > > >What do you think about, dear colleagues?
> > > >
> > > >Stanislav Korobov, PhD
> > > >PO Box 7, Odessa, 65089, UKRAINE
> > > >
> > > >[log in to unmask]
> > > >[log in to unmask]
> > >
> >