Hi Jenny,
To start, I did try to read the article in it's entirety. I must confess
that I had a heck of a time following the logic and got caught up a myriad
of what I consider exaggerations or unsupported assertions. It took me 4 or
5 attempts to get through the entire paper, and I'm still not sure if I
understand all of Flic's points. I guess I'm not used to reading this type
of paper.
I sincerely appreciate your concrete example about living conditions
affecting life expectancy but wonder how we might incorporate something this
general into the process of medical decision making (practical application
of EBM). I believe it would be more clear, concrete, and actionable if you,
Flic, or anyone else who thinks the current EBM process is lacking were to
suggest something more specific like "Sanitation levels affect prevalence of
parasitic diseases and related morbidity/mortality, and EBM does not
specifically address sanitation levels as a factor in medical
decision-making." Acknowledging the fine work done by our colleagues that
practice in the area of Public Health, I think the implications of this
assertion may be limited in developed countries, but a factor to consider if
practicing in less-developed countries and, perhaps, economically depressed
areas of developed countries. By the way, I hardly think this is a lack of
awareness but rather the intentional filtering of "likely relevant" vs "not
likely relevant" information based on locale and patient living conditions.
My interest in advancing the acceptance of EBM includes both educating
people about EBM (based on my present understanding) and working to make EBM
more applicable to a wider audience. My entire motivation for this
discussion thread was to try and determine what specific factors are missing
from the triad identified in our current EBM paradigm - clinical experience,
patient preference, best scientific evidence. So far, the best I can come
up with is "patient living conditions". What else am I missing?
By the way, I believe that the medicalization (really should be called
"diseasification") of normal physiologic processes is something we all
should be concerned about. It is particularly alarming when multinational
pharmaceutical manufacturers use "diseasification" as a tool to market their
products. see: Moynihan R. BMJ. 2002 Apr 13;324(7342):886-91
Regards,
Eric
----- Original Message -----
From: "Jenny Advocat" <[log in to unmask]>
To: "Eric Harvey" <[log in to unmask]>
Cc: "Jenny Advocat" <[log in to unmask]>;
<[log in to unmask]>
Sent: Sunday, July 18, 2004 10:17 PM
Subject: Re: Medicalisation and EBM
Hi Eric, thanks for your response. Two things quickly come to mind. First, I
suggest you read the article that sparked our discussion. It may not be the
best example of this type of critique, and it certainly isn't the only one,
but it's a fine starting point. An example from it is around the diagnosis
and treatment of CFS. Filc is using CFS to suggest that biomedicine reduces
symptoms to individual behaviours and suggests treatments which maintain the
distinction of CFS as the individual's responsibility (p1279-1280). While I
would argue this is surely part of the story, the reality of CFS (and most
other diseases) is that it exists also in a particular social context (see
Filc's reference to Scheper-Hughes and Lock 1987, who use a heuristic of the
'three bodies' to characterise the complexity of the inter-relatedness of
the individual body-which biomedicine is particularly adept at acknowledging
and treating-with the social and political bodies-which biomedicine, as Filc
argues, systematically ignores). A straightforward example of this lack of
awareness can be seen as well with Filc's example of better living
conditions working to increase life expectancy, in this way taking the
responsibility off of the individual body and placing disease in the context
of the social world (i.e. living conditions). There are many many journals
and texts that you could check out to learn more about this area. The
journal in which Filc's article appeared (Social Science and Medicine) is a
great starting point and Medical Anthropology Quarterly is another good one.
My second point is more to do with EBM and methodology, I suppose. I'm
interested that you say that you are "interested in advancing the acceptance
of EBM by as many people as possible." I wonder if you are also interested
in working on making EBM more applicable to more people through
incorporating new methodological practices, which could work to not only
spread your message (as it stands currently) but also to make it more
meaningful and more relevant to more diverse populations by recognising the
way in which local practices and contexts impact upon the health of
individual bodies? I'm new to the field, but it seems to me one thing to
use consumer networks and claim an interest in qualitative perspectives
(interest claimed, but given the response to Filc's article, respect may not
yet be won) but quite another to be able to actually incorporate these
opinions and experiences into the practice and philosophy of EBM. It's my
understanding that these methodologies aren't yet completely worked out and
we are still in the process of figuring out best practice around these
concepts.
With enough interest and mutual respect from both sides, I imagine there
could be innovative and practical ways (new methodologies) to integrate
these social realities with those types of biological/individual realities
that are already acknowledged by EBM, therefore creating an even stronger
evidence base.
In short, I guess I would venture that this is largely a case of important
and unaddressed considerations!
Eric Harvey <[log in to unmask]> wrote:
> Jenny,
>
> Thanks for your clarifying comments. Let's say I acknowledge that social
> sciences and EBM may be guided by different epistemologies (ignoring
> whether
> or not I think this is a good thing). Since I am interested in advancing
> the acceptance of EBM by as many people as possible and claim no personal
> expertise in the intricacies of social sciences, I would be grateful for
> you
> or some other expert in social science matters to explain to me exactly
> what
> social dimensions of people's lives are not routinely being included in
> medical decision-making that follows an EBM process.
>
> My aim is to determine if this is simply a case of misinterpretation of
> terms or an important, unaddressed consideration.
>
> Eric
>
> ----- Original Message -----
> From: "Jenny Advocat" <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Saturday, July 17, 2004 8:44 PM
> Subject: Re: Medicalisation and EBM
>
>
> In response to the critique of Filc's article in Social Science and
> Medicine, I have a couple of comments:
>
> Firstly, the article is a critique of specific articles in a specific
> journal, which are analysed to illustrate the way(s) in which the social
> dimensions of health/illness are often neglected in biomedicine. It is
> not
> a condemnation of all things biomedical (see bottom of page 1276,
> particularly the inclusion of Lupton). Secondly, the article is one of a
> long tradition within the social sciences to critique current practice
> within biomedicine. Wouldn't it be possible, more useful, as well as more
> interesting, to consider the ways in which a critique like this may
> intersect with the philosophy of EBM-instead of so quickly attempting to
> delegitimise it? (Really, this article reflects rigorous social
> scientific
> work, and in my opinion it is simply wrong, as well as not useful, to
> compare it to the Sokal hoax; taking the critique down the path of
> pop-'post-modernism' seems just silly, and unfair, to me). The article
> may
> (or may not) leave some things to be desired by proponents of EBM, but I
> would argue that in order for any of us (social scientists and EBM
> proponents) to succeed in practicing interdisciplinarity we should use
> articles such as this one to open up discussions around the methods that
> could be used to work towards common goals such as improving health care
> practices etc.. If there is (and I think there probably is) critical
> reflection within EBM, this should be articulated in a critique of this
> article. At present, it is not well articulated and in characteristic
> defensiveness the response has, instead, been to simply bring up the fact
> of
> consumer input.which does not speak to the point made in this article:
> simply that biomedical research and practice does not often include a
> consideration of the social dimension of people's lives. More
> interestingly, I think, this article and the response to it, point to
> starkly different epistemologies guiding EBM and the social sciences. Our
> job, then, is to discover how these different ways of thinking may be
> brought together to achieve common goals.
>
>
> Jenny Advocat, PhD Candidate
> Austalasian Cochrane Centre
> Monash University
> Melbourne, Australia
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