Dear List,
I recently ran one of a series of workshops for general practitioner
registrars, on aspects of EBM. They were intelligent and receptive and it
appeared to have gone well. However, I was intrigued by a conversation at
lunch when one of the participants was earnestly and seriously recommending
that her friend should try a particular herbal remedy for her ailment. The
justification was, "It cleared my problem up really quickly." It
demonstrated that the messages of that day and of previous sessions had not
really got through. There was still the uncritical acceptance of anecdote as
a basis for decision making, the failure to distinguish Necessary from
Sufficient evidence, not to mention the lack of awareness of the problem of
uncommon serious adverse effects and the difficulty of knowing the
probability of these. The latter had been dealt with in an exercise about
the use of new drugs and risks of uncommon side effects; Hanley's Rule of 3
had been discussed.
This is not the first time I have felt that the teaching of EBM may not be
reaching deeply enough and may not address the basic issues about what
individuals accept as "evidence". (I don't think this is purely an
inadequacy of my own teaching because I have noticed problem in other EBM
workshops.) I wonder if the more basic assumptions and individual frameworks
used to decide "What is", and "What is not", should be examined with
students initially? Does my young doctor demonstrate the need for students
to examine and understand their own underlying philosophy before EBM is
"grafted" on? Will there not be "rejection" if the underlying personal
framework is incompatible with EBM philosophy?
Others have commented on the increasing interest in complementary therapies,
many with little empirical evidence to support them, among the new
generation of British general practitioners. Could it be more important for
the educated practitioner to have a clear understanding of his/her own
underlying frameworks, and where his/her decision making is coming from,
than to understand a likelihood ratio for instance?
This of course is all in the territory of epistemology.
Do others have these thoughts and reservations?
Do the many more experienced teachers of EBM on this list include some basic
epistemology in their teaching?
Adrian Roberts
General Practitioner
Constantine
Falmouth
Cornwall
UK
|