Michael, a couple of weeks ago or so, I commented that the "classic" definition of EBM ("the integration of best research evidence with clinical experience and patient values") is inadequate and should change (if the goal is to improve decision-making). A couple of people sent me their personal notes asking me to explain what exactly I meant by pointing to the impossibility of integration of descriptive aspects of decision-making (e.g. personal experience) with normative one (e.g. unbiased evidence) to derive prescription for optimal decision-making. I responded with a couple of examples illustrating how experience is so prone to error that we can never be sure that integration of particular experience with best evidence will in fact lead to optimal prescriptive course. For example, I have a colleague who once missed brain tumor in the patient complaining of headache. Ever since he has used this "experience" to justify ordering imagining studies in all of his new patients presenting with headache. As I was rounding this am, I saw tons of tests and treatments being ordered based on someone's "experience". In most of these cases, it would be difficult to argue that the decisions that were made (and are being made in thousands of other patients on daily basis) represent an optimal course of action (despite the fact the actions in all of these cases met classic definition of EBM). (I am not only talking about heuristic and biases that shape everyone's experience...)
So, I suggest again that we abandon the impossible dream and re-define EBM. (I personally favor David Eddy's definition of EBM as a "set of principles and methods to
ensure that, to the greatest extent possible, population-based policies and individual decisions are consistent with evidence of effectiveness and benefits").
ben
-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Michael Power
Sent: Friday, August 07, 2009 8:29 PM
To: [log in to unmask]
Subject: Re: Medical humanism and evidence-based practice may collide
Hi Carlos
Groopman and Hartzband use a definition of EBP that I am not familiar with. They say evidence-based practice "aims to put medicine on a firm scientific footing; experts evaluate the best available data and develop clinical guidelines designed to standardize procedures and therapies".
The second edition of How to practice and teach evidence-based medicine by David Sackett, Sharon Strauss, W Scott Richardson, William Rosenber, and R Brian Hayns defines EBM as "the integration of best research evidence with clinical experience and patient values". The book was published in 2000.
I suspect that the author's chose their narrow definition (thus creating a false dichotomy) so that they could make their article more dramatic, for example by using the image of medical humanism colliding with EBP. In fact EBP coalesced with medical humanism at least 9 years ago. If EBP is imperfectly practiced, this is evidence of a problem with the practice, not with EBP.
Michael
________________________________
From: Dr. Carlos Cuello [[log in to unmask]]
Sent: 07 August 2009 16:43
Subject: Medical humanism and evidence-based practice may collide
I would like to hear opinions on this
NEJM: Groopman, Hartzband: Medical humanism and evidence-based practice may collide.
http://bit.ly/4YWm3
--
Carlos A. Cuello-García, MD
Director, Centre for Evidence-Based Practice-Tecnologico de Monterrey
Cochrane-ITESM coordinator. Professor of Paediatrics and Clinical Research
Avda. Morones Prieto 3000 pte. Col. Doctores. CITES 3er. piso,Monterrey NL, México. CP64710
Phone. +52(81)88882154 & 2141. Fax: +52(81)88882019
www.cmbe.net<http://www.cmbe.net>
The content of this data transmission must not be considered an offer, proposal, understanding or agreement unless it is confirmed in a document signed by a legal representative of ITESM. The content of this data transmission is confidential and is intended to be delivered only to the addressees. Therefore, it shall not be distributed and/or disclosed through any means without the authorization of the original sender. If you are not the addressee, you are forbidden from using it, either totally or partially, for any purpose
|