At 10:35 AM 9/7/03 -0400, Djulbegovic, Benjamin wrote:
>2. Regarding Roy's point that "In real time one often has to follow back
on clinical policies or rules of thumb. However, my hope is that these
clinical policies can be informed by evidence based medicine as much as
possible", this is exactly what I hoped it would happen. Several years ago
I even wrote: "These rules (heuristics) (which often are dysfunctional)
should be identified in each field, and then scrutinized....they should be
then further developed based on evidence of the highest quality....".
However, this is simply not happening.
>Regarding Roy's other points, of course, I agree with them. The problem is
specificity. When you are faced with the problem X, about which you don't
know what to decide, what intervention to recommend, not being familiar
with benefits and harms (and hence not being able to elicit the patient's
values about them), what do you do? Ask a resident to provide us with an
answer using EBM paradigm or call a consultant? We, and I guess you as
well, ask for a consultant 99% of time. (Of course, I give my team a
teaching assignment, but the results of the process-according to EBM
paradigm-may not come back in a real time to be useful). (We should also
remember here that solving the patient's problem comes first, and then
teaching.)
>3. Regarding David's point about EBM experts, it is exactly the
denouncement of the (content-specific) expertise which started EBM
revolution. Earlier in the process Feinstein sensed that a call for new
expertise is being promoted writing: ...critical appraisal of evidence is
not an easy task. Consequently, interpretative decisions by old pre-EBM
experts may be replaced by interpretative decisions from a new group of
experts with EBM credentials...." Leaving aside several centuries old
debate what is expertise and who has the best qualification to ascertain if
the findings reflect "the truth", my main point is that content-specific
expertise still dominates medicine and will likely continue to dominate
since that is the way how division of labor is arranged in medicine. In his
earlier e-mail, Victor had an intriguing idea suggesting to use
(sub)specialists as "evidence brokers". This is probably what is going to
happen (at least in the US). (Sub)specialists will slowly embrace basic
concepts of EBM (as some of them already have), but using EBM as
"problem-solving technique" at bedside as initially promoted will not
happen, I am afraid.
But hopefully we can persuade the content-experts and/or consultants of the
value of the EBM approach, and if we can add EBM to medical education, we
can begin to persuade new content experts and consultants that it's
valuable. My guess is that in the UK, where consultants are not (over)paid
for every procedure they do, that they will eventually become amenable to
this approach.
The main opposition in the UK, I would guess, would come from the managers
and bureaucrats whose self-interest EBM threatens. Remember that when one
starts to address a question using the EBM process, one doesn't know the
answer. It may be that treatment X, despite being very expensive, is
worthless or harmful (which harms the self-interests of those who make
money from treatment X). It might be that treatment X, despite being very
expensive, is very worthwile (which harms the self-interests of the
government which wants to reduce costs.) My guess is that one reason EBM
has been slow to catch on has been the instinctive opposition by those who
realize that by giving an ultimately unbiased answer, EBM threatens their
interests.
Of course, things are much worse in the US, where the health care system is
dominated by a variety of organizations, not just the government, and
pharma and device producers, but also managed care organizations, huge
hospitals, and hospital networks, etc, each with their own set of
self-interests, and most managed by people with little background in or
sympathy for the values of health care professionals.
...............................................................
Roy M. Poses MD
Director of Research, General Internal Medicine
Brown University Center for Primary Care and Prevention
Memorial Hospital of Rhode Island
111 Brewster St.
Pawtucket
RI 02860
USA
401 729-3400
fax 401 729-2494
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