Taking a step back, suppose most doctors feel searchable evidence is 
increasingly irrelevant, why might this be? I think this whole thread misses 
a more central problem



I am interested in EBM, and believe that EBM is very important to guide us, 
but I believe the emphasis on blindly pursuing the technology of EBM, as in 
this thread, carries serious hidden dangers.



How do people, including doctors, use digital/medical technologies, what 
impact is it having upon their values and cultures and behaviours and the 
doctor-patient relationship. If McLuhan (The medium is the message) and 
Heidegger ("The question of technology") are right, then, constrained, 
driven and wrapped up by fast digital capitalist information flows (Taylor), 
doctors are becoming less interested in the content of what they are doing 
but are instead driven by their Performance Enframing Frameworks (PEF 
represented e.g. in UK Primary Care oxymoronically by the technopolists as 
Quality Outcome Framework, QOF) , which is a closed/gated minimum competence 
framework.  (in a broader societal sense, outside of the consultation, 
doctors like other members of society are now living "empty commodified 
anomic existences in an eternal now" (q.v. Taylor), seeking to consume and 
to have the digital 'buzz' of technology continuously in their ears.) 
Doctors are not seeking 'evidence' for this would imply that they feel they 
can influence the content of the consultation, whereas doctors are being 
subtly encultured to (subconsciously) behave as if the content of the 
consultation is pre-determined by 'the system' whilst deludedly believing 
they still have control.  Instead they are vacuously seeking to fulfil the 
requirements of the system (La Techne, Ellul) and are being rewarded for 
doing so, whilst losing their core humanity.



Much of so called EBM, and guidelines involves using technology which causes 
the doctor to withdraw from the patient's reality, the doctor-patient 
relationship becomes more shallow, more like a reified commodifed 
customer-business transaction.  EBMers have encouraged the framing of 
'answerable' questions, but this means that the patient's situation has to 
be artificially simplified, squeezed into a quantifiable rationality, in the 
rush to get to an answerable question the patient is lost.  Now the content 
of the consultation is so enframed by the technology of the system that GPs 
no longer have to ask any questions.  In 'fast capitalism' on-line 
programmes will replace much of what the GP is doing today, GPs and the 
population at large are being encultured not to expect the GP to have an 
apostolic function, or a psychotherapeutic function.  Doctors will be 
'guided' by the PC to follow guidelines ever more faithfully, as 
technologies advance and more (profit) becomes possible ( further vaccines, 
preventive medicines, more diseases, genetic engineering) Doctors are 
becoming so wedded to obedience to the technology they will no longer 
question the wisdom, but will blindly follow.  Nothing will be left to 
chance (the doctors 'judgement' no longer necessary), e.g. the need to use a 
questionnaire to diagnose depression - the doctor withdraws from the patient 
, the technology is a barrier, it determines the doctors behaviour and turns 
what should be a meaningful human interaction into a mechanistic one.  e.g. 
calling in a 41 yr old asylum seeker from the Congo with a history of 
torture and rape to have her 10 yrs CVD risk assessed.  The technology is 
there so we feel it has to be used, doctors can't be trusted to use their 
judgement so there are guidelines and Big Brother is watching you, as your 
behaviour is faithfully recorded digitally.



The big question isn't so much how should doctors access evidence, its about 
ensuring that doctors are aware of the enframing effects of the system and 
of the technologies and are not in thrall to the fascination of conforming 
to guidelines and PEF demands, doctors must not 'withdraw from the 
withdrawal' (Heidegger) (must not be blind to the fact that technology is 
enframing them and taking over the content of the consultation) or the 
central humanistic aspects of healthcare will be lost, its about changing 
the types of research question being asked, putting less emphasis on 
longevity, more on quality of life.  Putting more evidence on doing less 
harm and not medicalising healthy people, thinking about people's mode of 
death (qv Iona Heath), not glibly exercising interventions to prevent one 
type of death just because we can, and having a bit more explicit honesty 
about the limitations of interventions and the true meaning of an NNT of 20.



Medical students and doctors seem to believe that all treatments are 
effective for all patients and that it is their duty to educate patients of 
the need for them to take such treatments, once educated that's the doctors 
job done.  The technology has been used, recorded, the doctor has been paid 
( handsomely)  - end of story.  How could the technology ever be 'wrong'?



Lets undermine Performance Enframing Frameworks, with their financial 
incentives and pay more attention to what we really want the content of the 
consultation to be.  Lets stick with EBM, with digitally accessible 
guidelines by all means, but be aware of the serious danger of our 
domination by the technology and change the predominant research questions 
paradigm.



Owen, UK general practitioner





----- Original Message ----- 
From: "brnbaum" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, November 07, 2008 4:59 PM
Subject: Re: 1 full text or 5 abstracts?


There are important truths in Ben's response about time being a limited & 
vital resource, and Jon's observation that we're missing something more 
fundamental in how evidence is packaged for effective delivery.  Jon's point 
is true for the general public as well, given recent evaluation of hospital 
comparison websites usage (<5% of Americans used well-established websites 
to inform a decision in the year prior to the published survey according to 
a recent Robert Wood Johnson Foundation report, and most of those surveyed 
distrusted the information sources). Like, Jon, through Applied Epidemiology 
I produce an annotated index but for a different segment of the healthcare 
market (hospital epidemiology & infection control). Two impediments seem 
evident from my experience with that: low numeracy and epidemiological 
understanding levels make many reluctant to apply the critical appraisal 
necessary to understand evidence behind guideline statements, and reliance 
upon published guideline statements without questioning limits to 
interpretation has become a widespread habit. Unless we can package more 
complex displays of the evidence in a convenient manner, and in formats that 
are more readily understandable to most, it will be a tough road ahead. The 
alternative is to raise the bar of practice standard throughout our 
respective fields, a equally challenging continuing professional education 
development task.

David.

--
David Birnbaum, PhD, MPH
Adjunct Professor
School of Nursing & School of Population and Public Health
University of British Columbia
Principal, Applied Epidemiology
British Columbia, Canada


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