Dear all,
This is an interesting discussion as some of those with whom I have shared
my interest in EBM seemed to think I may have to vacate thinking and
decision making in favour of being only a statistical guru for EBM. Perhaps
it is an old line view and the discipline has evolved dynamically. In my
estimation experience and evidence work together to shape decision making
and communication and it is not an either/or experience. If the clinician
sharing her interpersonal experience with reality had only this and no EBM
knowledge to draw on she would be handicapped and drawn to the crisis mode
rather than engaged in the discipline of strategic practice to solve the
problem using either system 1,2 or a combination of both. I could also say
evidence without understanding and application is a little like a car with
no fuel. Part of that understanding would be based on a clear understanding
of what we base evidence on and how this could be different from the way it
is perceived in the everyday world.
I do remember years ago in a medical/legal situation I was involved with the
medical professional involved said with most probable medical certainty I
can testify that etc. At that point all I could think of was if they weren't
certain and didn't know the truth or have the proof why didn't they get
someone who did...The patronising response "Oh it will be fine it is just
the language" did nothing to allay my concerns...
Best regards,
Amy
Amy Price
Http://empower2go.org
Building Brain Potential
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Hutchinson Andy
Sent: 07 July 2011 11:46 AM
To: [log in to unmask]
Subject: Re: EBM Anecdote: Today's NEJM
Thanks Hilda
It also occurs to me that when politicians (who often have a legal
background, at least in the UK) talk about 'evidence-based policy making',
they may well mean "well, we have taken testimonies from witnesses e.g.
clinicians, members of the public". The fact that those people's ideas,
thoughts, views, etc will be influenced as much by their mindlines,
prejudices and assumptions as what we in this group might think of as
evidence, does not always seem to be considered
Andy
Andy Hutchinson
Education and Development Manager
Tel: 07824 604962
Web: www.npc.nhs.uk
email: [log in to unmask]
Please note new website address
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Bastian, Hilda
(NIH/NLM/NCBI) [C]
Sent: 07 July 2011 16:26
To: [log in to unmask]
Subject: Re: EBM Anecdote: Today's NEJM
G'day!
I think this is one of the problems with the word "evidence": so many people
see any "fact" as "evidence", because that is, as you say, how the word is
used elsewhere (as in "evidence of my own eyes"). However, an RCT, because
it is a formal experiment, has probative value. That's a critical
distinction that used to be made where I first learned about evidence -
which was when I worked in courts. Just because information is organised and
systematic, does not necessarily mean it has probative value.
Yet, some of us see the word "evidence" as meaning "proof" (ie having
probative value), but most people probably don't. It's often pointed out
that evidence doesn't mean proof in languages other than English - but it
doesn't really mean only specifically that in English either.
In the world outside the EBM field, an eyewitness account and even
circumstantial evidence are still evidence. It's a more complicated word in
English than we think, and the community view of it must surely be more
influenced by the legal use of the word (especially in a world where police
and legal procedural TV shows are so widespread and popular), than by any
re-purposing of the word health care tries to make.
And that includes the different idea of the onus of proof. I had absorbed
clearly when I worked in the courts, that proof means, more likely than not.
It was called "the balance of probabilities" and it just had to tip 51%.
When I entered the EBM world, I found out that "probable" in this world was
set at 95% (or sometimes 90%). That's a gulf that is enormously wide.
Suffice to say, I'm not sure evidence is a good term for what many of us
mean, and I've started to avoid using it when I'm writing in English, too.
Hilda
From: "Bill Cayley, Jr" <[log in to unmask]<mailto:[log in to unmask]>>
Reply-To: "Bill Cayley, Jr" <[log in to unmask]<mailto:[log in to unmask]>>
Date: Thu, 7 Jul 2011 08:49:59 -0400
To:
"[log in to unmask]<mailto:[log in to unmask]
AC.UK>"
<[log in to unmask]<mailto:[log in to unmask]
AC.UK>>
Subject: Re: EBM Anecdote: Today's NEJM
I think the most pithy part of the article is the phrase: "Informed adverse
anecdote transforms scattered data into sound clinical judgment"
To my way of thinking (OK, so we're starting w/ anecdote already!) evidence
is simply "any observation" - the difference between anecdote and RCT and
meta-analysis is simply the degree to which the evidence is ORGANIZED and
SYSTEMATIZED. Still, it takes real-life, clinical experience to know where
to look and have the perception of nuance to know how to organize the
evidence.
Bill Cayley, Jr, MD MDiv
[log in to unmask]<mailto:[log in to unmask]>
Work:
Augusta Family Medicine
207 W Lincoln, Augusta, WI 54722
Tel: 715.286.2270
Pager: 715.838.7940
Home:
3604 Sharon Drive, Eau Claire, WI 54701
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Mobile: 715.828.4636
A cheerful heart is good medicine... (Proverbs 17:22)
From: Rakesh Biswas
<[log in to unmask]<mailto:[log in to unmask]>>
To:
[log in to unmask]<mailto:[log in to unmask]
C.UK>
Sent: Wednesday, July 6, 2011 11:19 PM
Subject: EBM Anecdote: Today's NEJM
To quote from: http://healthpolicyandreform.nejm.org/?p=14876&query=TOC
"The key is to use these flashes of physician anguish to illuminate the
Level I evidence and identify the real risk factors for a bad outcome. I
suspect the amygdala did not evolve to store odds ratios and heterogeneity P
scores, but when an adverse event has prompted me to review the literature,
I come away with a clearer understanding. There's nothing like a baby
free-floating in the abdomen to drive home the lessons from a prospective
study of risk factors for uterine rupture. And that clarity of understanding
will serve the next at-risk patient I encounter."
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