Michael, in my opinion beauty of EBM is in its PUBLIC character (its transparency, explicitness, accessibility to all of us- students and professors alike- who master EBM subjects such as critical appraisal, research synthesis techniques etc). Once you involve tacit knowledge (i.e. PRIVATE evidence which is not acceessible to others), you start having the problems I am trying to describe in our exchange (which, it appears, is becoming too tedious for some...). And, because as you and Don pointed out, we are yet to come with definition or understanding what rational or optimal decision-making is, I say that we need to seperate public evidence from private one and hence modify the current popular definition of EBM.
This should not be construed as a critique of the Sicily Statement, which represents an important advancement in the field...hopefully, my efforts to convince you all will be welcome as a constructive critique...Once again, I am not speaking against importance of expertise or patient values....Don has expressed my point more eloquently "from Kant to Moore to Curran to Beauchamp to Veatch...we are still looking for definitive mold"...and let's not decieve ourselves that we did find it (and along way damage the precious gem we did discover in the last 10-15 years...)
I promise I am going to stop here (but it is Carlos' fault:-) - his post has resonated too strongly...)
best
ben
________________________________________
From: Michael Power [[log in to unmask]]
Sent: Monday, August 10, 2009 12:07 AM
To: donald stanley
Cc: [log in to unmask]; Djulbegovic, Benjamin
Subject: RE: Medical humanism and evidence-based practice may collide
It would be interesting to see how definitions of EBM have changed over time. The "Sicily statement" in 2005 defined EBP as "A Evidence-based practice requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources." http://www.biomedcentral.com/1472-6920/5/1
This definition replaces "integration of expertise" with "informed by the tacit and explicit knowledge of those providing care". It seems to be saying that research evidence should be applied using expert clinical judgement.
Ben, whn you say "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", are you implying that there *is* a way ensure that clinical decisions are always optimal? I think this is would be an overoptimistic goal. Clinical decisions are necessarily made with uncertainty about the facts and outcomes. Although experts are subject to the "availability error", as you pointed out, are non-experts better at helping patients make the optimal decision?
Michael
________________________________________
From: donald stanley [[log in to unmask]]
Sent: 09 August 2009 13:52
To: Michael Power
Subject: Re: Medical humanism and evidence-based practice may collide
Dear Michael and Ben,
To see the same scenario, please compare it to the development of ethics
from ancients, through Kant to Moore to Curran to Beauchamp to Veatch to,
you get the point that all of these have struggled to inculcate values with
decisions and none of the strategies: virtue, rules, normative guides, have
proven reproducible and justifiable to all at all times. The discussion
around the definition of EBM or EBP seems to try to mold the clay in one's
own image, at this time, for this instance.
We are still looking for definitive mold.
Donald
[log in to unmask]
[log in to unmask]
> From: Michael Power <[log in to unmask]>
> Reply-To: Michael Power <[log in to unmask]>
> Date: Sun, 9 Aug 2009 03:26:21 +0100
> To: <[log in to unmask]>
> Subject: Re: Medical humanism and evidence-based practice may collide
>
> Ben
>
> You and I are talking about different issues. You are talking about
> integrating clinical experience with research evidence. I was talking about
> integrating values with clinical practice. I will comment on both issues,
> beginning with integrating clinical experience with research evidence.
>
> Your example shows that there is a problem with integrating clinical
> experience in your sense, which is the obvious interpretation of the phrase
> with research evidence. I interpret the phrase to mean the evidence on a
> particular patient gathered from the history, examination, and special
> investigation; this evidence needs to be integrated with research evidence to
> make a sensible decision about the appropriate clinical management. This
> definition of EBP needs to be rewritten!
>
> Although values always affect decisions, the EBP community has tended to avoid
> looking at how we integrate (or how we should integrate) patient-values with
> research evidence. Sometimes it can be difficult to decide what the
> appropriate decision is. For example, when a pregnant woman has a
> life-threatening disease, and treatment of the disease would be dangerous to
> the fetus. (For a detailed example, see Professor Michael Baum's Samuel Gee
> memorial lecture at https://admin.emea.acrobat.com/_a45839050/p69282078/. Skip
> to slide 36 if you are in a hurry. If you are not in a hurry he has some
> interesting things to say about concepts of holism in orthodox medicine and
> alternative medicine.)
>
> The literature on integrating values with EBP seems to have been largely
> written by Bil Fulford and his colleagues (I would appreciate pointers to
> other authors). The following link is to a paper that gives 10-principles of
> values-based practice and shows how values-based practice relates to
> evidence-based medicine.
>
> http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16954
> 004
>
>
> Michael
>
>
>
>
>
>
> ________________________________________
> From: Djulbegovic, Benjamin [[log in to unmask]]
> Sent: 08 August 2009 21:14
> Subject: Re: Medical humanism and evidence-based practice may collide
>
> 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
|