Hi Donna
One of the issues that comes to mind is that the terminology and criteria
for measurement of "bias" and "rigour" as used in quantitative studies
really don¹t  translate across other paradigms. Forms of qualitative
research answer important questions, but "bias" is almost a redundant
concept in qualitative evidence.

So should criteria be "less severe" or are separate, and appropriate
criteria for appraisal that carry equal weight the answer?  Certainly there
are organisations - such as the Joanna Briggs Institute that accepts
research evidence regardless of paradigm as being more rigorous than expert
opinion and has methods of attributing levels of evidence across paradigms -
I would argue that its not just nursing that needs a more pluralistic,
inclusive approach to evidence - allied health,  and medicine also have
questions that are not solely focused on effectiveness.  Cochrane has a
qualitative methods group, the Campbell collaboration has similarly eclectic
information needs, and the Joanna Briggs Institute has long been a leader in
this area.

Regards
Craig

> RE: "Is this a justifiable state of affairs, or should there be less 'severe'
> exclusion criteria so that valuable evidence can be gleaned from 'less
> rigorous' studies?"
> 
> What happened to grading the evidence? I have been around EBP long enough to
> remember that initially, guideline development included the use of grading
> systems to denote the 'level of evidence' used in making the recommendations.
> Have we forgotten that a clinician and patient/client can actually use their
> own judgement and experience to make up their mind about whether the
> recommendation is appropriate in a given context (as long as they are fully
> aware that guidance may come from 'less rigourous' studies)?
> 
> The idea of formulating guidance (only) from RCTs has always been a problem
> for nursing. Nursing questions are sometimes best answered by other methods
> (as has been pointed out in this discussion thread already). Matching the
> 'kind' of clinical question to the most appropriate study design has been a
> sensible way for nurses to proceed towards evidence-based nursing practice,
> but doesn't always cut it with EBM devotees. I also think the way EBM has been
> 'sold' in nursing (mostly by nurses themselves) has not made this clear to a
> profession which is dedicated to patient/client 'care' (which does not always
> translate to an intervention or treatment) and is still maturing as an
> academic discipline (in Australia anyway).
> 
> I joined this list in 1998 and I don't think I have ever posted anything - but
> Ronán Conroy's posting made me laugh so hard...it has made my day and thank
> you all for a most interesting discussion. It all seems very healthy to me!
> 
> 
> Donna Waters
> The College of Nursing
> Sydney, Australia
> 
> -----Original Message-----
> From: Evidence based health (EBH)
> [mailto:[log in to unmask]] On Behalf Of Mark Pearson
> Sent: Friday, 25 August 2006 1:01 AM
> To: [log in to unmask]
> Subject: Re: Deconstructing the evidence-based discourse in health sciences)
> 
> I am in agreement with much of what has been said about the Holmes et al paper
> - it has a cavalier attitude towards making sweeping statements based on
> tenuous evidence, and (problematic though such research may be) the apparent
> unwillingness to conduct methodologically rigorous research on (e.g.) the
> Cochrane Collaboration does not help their case. Despite all this, I still
> think that Michael has a point when he says that "the ideas aren't that
> outrageous... any group defines ways of doing things that excludes others" -
> maybe this is at the root of the authors' use of the word 'fascist' - they had
> gotten fed up not being listened to, and thought that courting controversy
> might be the best option for stimulating debate about the issues concerned
> (and perhaps it has worked, going by the postings on this and the Evidence
> Network mailing lists!)
> 
> 
> 
> I would like to ask some of the other members to elaborate a little more on
> their postings if possible, in the main because it seems that their
> experiences of EBM are so polarized that I have trouble reconciling them. Roy
> states that he has found it "hard to get EBM related concepts into medical
> education [and] funding for EBM work", whilst Owen states that his involvement
> with the education of primary care Doctors and Nurses has been notable for its
> production of practitioners who "just want to be told who to prescribe what
> to". I think what Owen is getting at here is that despite EBM's ideal of
> integrating diverse forms of knowledge (research evidence, Doctor's
> experience, patient's values), the effect has been to produce practitioners
> unable to think. Yet Roy is concerned that EBM concepts have not affected the
> practice of medical education enough!
> 
> 
> 
> In response to Michael (Power), who criticises the rationale in the paper for
> stating that "98% of literature is deemed scientifically imperfect". Yes,
> there are some research questions that can only be rigorously answered using a
> particular method, but there are also many that require the melding of
> knowledge from a number of different methods in order to be adequately
> answered. In my own research in Public Health at NICE, broadly stated it may
> be said that there is concern from the expert committees about (and a somewhat
> lethargic institutional recognition of) the 'whittling away' of research on
> the basis of a hierarchy of evidence, only to be left with 1 or 2 RCTs (out of
> an initial 1000+ citations) upon which to formulate guidance. Is this a
> justifiable state of affairs, or should there be less 'severe' exclusion
> criteria so that valuable evidence can be gleaned from 'less rigorous'
> studies?
> 
> 
> 
> Mark Pearson
> 
> School of Law and Social Science
> University of Plymouth
> 20 Portland Villas
> Drake Circus
> Plymouth 
> Devon 
> PL4 8AA
> 
> 
> ________________________________
> 
> From: Evidence based health (EBH) on behalf of James Woodcock
> Sent: Thu 24/08/2006 11:26
> To: [log in to unmask]
> Subject: Re: Deconstructing the evidence-based discourse in health sciences)
> 
> 
> Michael,
> 
> I think you are too harsh on deconstructionism. Any method can be used badly.
> I think it is noteworthy that their article was not published in a sociology
> journal, my guess is that it would not have been accepted.
> 
> James
> 
> 
> Roy, thanks for bring this paper to our attention.
> 
> I wonder how the authors (and their supporters) would feel sitting in a court
> where the only "evidence" allowed was accusations and testimony by their
> enemies. This is how fascism works, and this is how Dave Holmes RN PhD, Stuart
> J Murray PhD,  Amélie Perron RN, PhD(cand) and Geneviève Rail PhD judge
> evidence-based healthcare.
> 
> To justify this assertion I shall deconstruct one of their deconstructions.
> They say
> 
> "For example, one of the requirements of the Cochrane database is that
> acceptable research must be based on the RCT design; all other research, which
> constitutes 98% of the literature, is deemed scientifically imperfect."
> 
> The supporting citation is not to the Cochrane Library or Manual of systematic
> reviews, but to "Traynor M. The oil crisis, risk and evidence-based practice.
> Nurs Inq 2002; 9: 162-9."  By relying on bigoted and uninformed testimony
> rather than evidence they demonstrate a fascist disdain for the truth. They
> also demonstrate a common psychological failing: seeing your own faults
> magnified in other people.
> 
> Similarly, to talk about "the Cochrane database" in this way demonstrates
> their ignorance of what the Cochrane Collaboration does. The Cochrane Library
> has about 6 databases or registers (counting is problematic because it is
> difficult to tell from the website whether a "product" is a separate database
> or a filtered view of a larger database). If they wanted to refer to the
> register of controlled trials they should have said so. But, if they had done
> this it would have exposed the wooliness of thinking in the accusation that
> 98% of the scientific literature is imperfect.
> 
> Putting in the number "98%" demonstrates another common psychological failing:
> when you are insecure, throw in a few pseudofacts to cover your ignorance.
> Have they (or anyone else) tried to count "all other research"?
> 
> My final deconstruction (I could go on, but it would be pointless) is to note
> the scope of the accusation that "98% of the literature is deemed
> scientifically imperfect". Holmes et al conveniently do not answer the
> question "Imperfect for what?".  If it had occurred to them that this is an
> important detail they would have soon realized that science has a large
> toolbox of study methods, and good scientists use the appropriate tool for the
> job. Only a deconstructionist could imagine that an RCT would be used to
> assess the management of avian flu in a particular country. An observational
> study is needed. 
> 
> Deconstructionists avoid details and facts because they impair their ability
> to insinuate, slur and slander, and because this might highlight the absence
> of constructive criticism. This is a pity, because there is much room for
> improvement in the aspirations, rhetoric and practice of evidence-based
> healthcare. It is a double pity because people who are aware of the
> shortcomings of evidence-based healthcare too easily accept fascist-style
> judgements about evidence-based healthcare.
> 
> Deconstructionism is fascist surrealism.
> 
> Michael
> ========================
> 
> Michael Power MD
> Clinical Knowledge Author, Guideline Developer and Informatician
> Prodigy Knowledge http://www.prodigy.nhs.uk/
> 
> ______________________________________________________________________
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> 
> 
> Hi Roy et al,
> I've read the paper today and found it readable and pertinent. I've been a
> UK GP for a large number of years and work in a deprived inner city, have an
> MSc in health sciences and clinical evaluation and have taught EBM. I agree
> with the paper, in the UK we have edicts from NICE telling us what to do
> with our patients, we are even financially rewarded for measuring all sorts
> of things, I am told that I 'should' now be screening diabetics for
> depression now (never mind the opportunity cost for what else I could do
> with that time), we 'should' be getting blood pressures below this and that,
> research papers still distort the truth a) by quoting relative risk
> reductions and b) by asking research questions that assume longevity is the
> gold standard and b) giving undue weight to confidence intervals bolstered
> by the internal consistency of the paper's stats, and c) assuming that just
> because a risk can be calculated that it is somehow accurate when we know
> that's a myth.
> Maybe most doctors just like to be told what to do and to be given a cookery
> book of recipes to follow. In my experience of teaching primary care doctors
> and nurse how to calculate risk, this isn't something they will do in the
> course of routine work, they just want to be told who to prescribe what to.
> They have often in fact stopped thinking about what they are doing.
> The public health specialists I've spoken to don't see individual risk
> communication as important, "Thats your problem" they say to me, a GP.
> Eminent epidemiologists have hailed the concept of the 'polypill' ignoring
> the implication that the majority of the over 40s will be pathologised and
> labelled as 'ill', with false expectations of what medicine can deliver
> fostering dependence, the EBM movement has embraced and imposed colonic
> cancer screening but the papers have inadequately measured changing health
> beliefs and the emotional adverse effects .
> I accept that EBM and the controlled trial has achieved a huge amount
> especially in therapeutics, but I suspect the current mania for
> 'preventitive' treatment and screening is doing more harm than good in
> preventitive medicine terms, and I am keen to avoid doing harm.
> I agree with the paper that the discourse of EBM is 'dominating' with its
> moral overtones, and that this does actively discourage and exclude
> alternative views, and the term fascism may feel nasty because of its
> historical connotations but I feel it is in fact justified.
> It feels especially healthy to have these sort of ideas aired, I feel they
> should be taken seriously.  Just read a few of the editorials in the BMJ,
> look closely at the language and the way its coercive intent on clinicians.
> This paper in fact feels overdue.
> As a way forward, I think we should take  a step back, research findings
> should be presented more neutrally, the adverse effects of screening for
> example should be explored in more depth, family practitioners should have
> more freedom to decide for themselves what treatments feel worthwhile
> without being incentivised to follow the rule of EBM edicts like sheep, we
> should enable and introduce more variability and innovation not seek to
> remove it.
> Owen
> Owen Dempsey
> GP
>