Dear all, thanks for this beautiful discussion.
While I haven't yet gone through the papers that are printing right now,
I can't resist to give my five cents of thought.
In fact, for about an year I have been tinkering with the concept of
epistemiology while teaching EBM to my students.
My point is that the world *is* complex, and just trying to convince
somebody that it can be made simple just formulating a PICO question and
checking a few lines on Clinical Evidence or Dynamed is both silly and
misleading.
My solution is that EBM should be learnt together with a reasonable
understanding of complexity and of some basic concepts of philosophy.
As for complexity, I found that the "Seven Complex Lessons in Education
for the Future" by Edgar Morin constitutes a great framework in wich EBM
can be graciously inserted. It fits perfectly in most of the seven
proposed domains, particularly in those of the uncertainity and
information and of course in the one on pertinence.
As for epistemiology, a few readings convinced me that EBM has been
closely built of the Popper's paradigm of science and on his
evolutionist model of the objective knowledge: it is practically
superimposable to the steps of EBM. And of course on the skeptic
principles abouth truth of Sextus Empyricus. Not to mention the close
application of the Hume's law on the distinction between the "is" and
the "ought": there is a beatiful discussion about this on Franz
Porzsolt's "Optimizing Health". Popper has also beautiful pages
explaining why an holistic knowledge (and hence a science of complexity)
cannot exist.
Therefore, I start my teaching with a brief introduction of these
concepts, and recall them all the way during our PBL sessions.
My impression is that the word "truth" has been somewhat censored out
from the EBM literature: you won't find this word in any of our
classical books or documents. This could seem wise considering the
common (wrong) criticism that EBM is pretending to impose some truth on
patients and physicians. But still the "truth" is really what knowledge
is about, so a basic understanding of what it could be is IMO very
preliminary to the approach to EBM.
For those unfamiliar with skeptic philosophy, Sextus Empyricus starts
his book explaining that when somebody ask a question about something,
there are three possibilities:
1)They think that the truth exist, and that they have found it: these
are the domatics (mostly stoics or epicureans)
2)They think that the truth doesn't exist or that it is impossible to
know. We would call then agnostics and relativists.
3)They think that the truth exists, and continue to search. These are
the skeptics, and this is the scientific perspective.
I hope to have some data to present in Sicily next November about my
experience.
I have also found two inspiring papers recently about evidence:
Evidence-based ethics--what it should be and what it shouldn't.
Strech D. BMC Med Ethics. 2008 Oct 20;9:16
(about the integration of ethical principles in EBM)
http://www.biomedcentral.com/1472-6939/9/16
and
The Struggle for Clinical Authority: Shifting Ontologies and the
Politics of Evidence, Uffe Juul Jensena1, Biosocieties (2007), 2:101-114
(about the role of the views of Alvan Feinstein and Archie Cochrane in
the development of EBM)
http://journals.cambridge.org/action/displayAbstract;jsessionid=F5969F31307EFFC3F0D8051F62B243B1.tomcat1?fromPage=online&aid=1002740
regards,
Piersante Sestini
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