Dear Ash, Owen and all
Before EBM, the fashion was Decision Analysis (see for example Llewelyn, D E H and Hopkins, A (eds) Analysing how we reach clinical decisions, Royal College of Physicians of London, 1993). This involved combining evidence from the literature with guesswork and the patient's values (represented by 'utilities'). The calculations to represent guesswork were complex and time consuming so the approach did not become popular. However, they did have the advantage of making the guesswork reasoning process TRANSPARENT and open to discussion. When decisions are made transparent, then the assumptions must also be made transparent, which include assumptions about what 'evidence' is considered to be relevant. If I understand Tudor Hart correctly, when he says 'ideology' he means those assumptions that determine what facts/evidence is assumed to be relevant. M. Hunink and P. Glasziou's 2001 book 'Decision Analysis in health and Medicine: Integration Evidence and Values' revisits this approach.
What I teach students and trainees in clinics and wards (and in the Oxford Handbook of Clinical Diagnosis) is that at very least they must describe what facts they have used to arrive at each diagnosis and decision, which provides a basic transparency. These 'FACTS' from the patient become the 'patient's particular EVIDENCE' when they are used to make predictions about a diagnosis or treatment outcome. These predictions are in turn used to make decisions. 'Evidence based medicine' involves trying to match as far as possible the 'patient's particular evidence' to some 'general study evidence' in the published literature (if it happens to be available), again in a transparent way if possible. Finally the predictions about what outcomes to expect are in turn used to predict their effect on the patient's well being (largely by guesswork) to allow a final decision to be made with the patient about what action if any to take. Ideally this would involve detailed explanations to the patient e.g. as advocated by Glyn Elwyn. In hectic day to day medicine this has to be done very quickly and usually in a non-transparent, intuitive way.
As doctors we are expected to keep reasonable records. So in the face of the complexity of medical decisions, my rule is that for each decision or action one must record explicitly a diagnosis (a group of predictions which led to the decision) and for each diagnosis one must record explicitly the 'evidence' from the patient which led to that diagnosis and its associated decisions (see the Oxford Handbook of Clinical Diagnosis). This is what I consider to be true evidence based medicine. Ideally we should also point to the corresponding supporting general evidence from groups of patients in the literature, but it may not be available of course. The patient's particular evidence used to make a decision is always available however.
Regards
Huw
________________________________________
From: Evidence based health (EBH) [[log in to unmask]] on behalf of Ash Paul [[log in to unmask]]
Sent: 11 May 2013 23:18
To: [log in to unmask]
Subject: Re: EBM and Person-centered care - can you have one without the other?
Dear Owen,
As far back as 2005, one of the foremost socially conscious GPs in UK, Dr Julian Tudor Hart, wrote in the BMJ that there was no evidence without ideology
Ref: http://www.bmj.com/content/331/7522/964.2
Prof Glyn Elwyn of Cardiff and Dartmouth Uni is now saying that it is now time to start moving away from point of care evidence-based medicine decison-making toolkits to point of care engagement toolkit (POCET)
Regards,
Ash
------------------------------
On Sat, May 11, 2013 17:29 BST OWEN DEMPSEY wrote:
>I think the praxis of EBM is where there is a fundamental problem with
>approaches such as shared decision making because this ignores the effects
>of the dominant culture within which those decisions are being made (or, in
>some cases, such as when women receive letters of invitation to go to
>breast screening, decisions are being forced upon people). I get the
>impression that most EBMers feel uncomfortable even discussing this. This
>might be, and I speculate here, because once we look at the effects of the
>dominant culture on decision making we have to examine the extent to which
>we have freedom (agency) or not (being 'determined') to act within that
>culture. Many so called post structuralists, after people such as Lacan,
>would argue that we have limited freedom, arguing that we are significantly
>'determined' by the dominant culture. This is made even more uncomfortable
>for EBMers since we then have to examine the effects of the culture from
>political and economic (ideological) angles, even dare I say it, to
>re-visit Marxist ideas about capitalism. So, the unregulated free market
>dominates the health industry now, leading to exceptional levels of
>overdiagnosis (and such things as corporate crime by the drugs industry,
>and even authoritative imperatives as in the latest BMJ, to 'innovate or
>die'). These considerations are all deeply political and ideological and
>critiques our commonly held views on human nature or subjectivity, but if
>we are serious about EBM and its praxis we shouldn't shy away from them.
>
>On Saturday, 11 May 2013, Phyll Buchanan wrote:
>
>> Thanks for all these thoughtful emails. You are all so kind at helping
>> think this through.
>>
>> Yes Nik, Its the Hunink and Glasziou book that started my thinking and now
>> you have reminded me I'm re-reading the last chapter and finding so much to
>> include in my presentation.
>>
>> I'm trying to build a case for the receiver of evidence-based information
>> rather than the giver of the information. We know the decisions won't
>> always be predictable but if they are informed, with a minimum of bias,
>> they will be right for the person.
>>
>> Michael and Neal, you have both described EBM being a journey. I like the
>> musical analogy and the RNLI model showing EBM is not a fixed thing but
>> something that is developing through discussions, evidence gathering and
>> within ourselves. Hilda, there are some rules, or maybe techniques to
>> guide us but as Amy has said, these will evolve too as we test
>> interventions?
>>
>> Using Myers Briggs will reach many in the audience who understand that
>> better than EBM and find it baffling how some decisions seem illogical. I
>> think is also relevant that person-centred care seems to have evolved from
>> Carl Rogers' work, even though it was about therapeutic change rather that
>> care or medical treatments. Chapter 7 of 'Becoming a person' describes a
>> process scale continuum along which individuals change from fixity to
>> flowingness, when a relationship develops between the therapist and the
>> client.
>>
>> This links with the idea of EBM being a journey which helps the
>> development of a trusting relationship between the patient/ client and the
>> practitioner - and my concerns about the potential risks in developing this
>> relationship detached from a commitment to explain the evidence.
>>
>> If we were to look at evidence of EBM influencing the receiver and helping
>> their decision making process we might describe the change from fixity to
>> flowingness as the development of self-efficacy and feelings of being in
>> control of decisions?
>>
>> This might only apply in long-term conditions like type 2 diabetes,
>> maternity care or interventions on behavioural change but I think it's the
>> difference between doing something because society (or the person caring
>> for you) expects you to behave in a certain way and making the decision to
>> do it because someone has taken the time to explain it to you in a
>> meaningful way even when it challenges your beliefs.
>>
>> Hunick & Glasziou sum it up beautifully: "The art of decision making is to
>> integrate the evidence and values. The art of living is to integrate the
>> head and the heart."
>>
>>
>> Phyll
>>
>>
>> On 10 May 2013, at 18:17, "Makretsov, Nikita [PH]" <
>> [log in to unmask]> wrote:
>>
>> The discussion is indeed interesting, but simple dichotomy “EBM efficient”
>> “EBM non-efficient” does not apply and is not quite testable. Some
>> religious people don’t need any proof of God, and I feel great about it.
>> The compelling evidence that EBM is working is in the nature of EBM the
>> methods of getting proof. Frequentist and Bayesian reasoning clash here,
>> but the result is not a complete annihilation as some may insist, but the
>> birth of a mechanism on how to transit from population research to
>> individual patient level.****
>>
>> The fundamental book of M.Hunink and P.Glasziou Decision Analysis in
>> health and Medicine: Integration Evidence and Values is indeed a classic
>> text and the compelling answer.****
>>
>> Sure it is all about how to benefit the community with the most efficient
>> medical interventions using the resources they have.****
>> * *
>> *Nik*
>>
>> ------------------------------
>> *From:* Evidence based health (EBH) [mailto:EVIDENCE
>> [log in to unmask]] *On Behalf Of *Hilda Bastianazza
>> *Sent:* Friday, May 10, 2013 5:41 AM
>> *To:* [log in to unmask]
>> *Subject:* Re: EBM and Person-centred care - can you have one without the
>> other?****
>>
>> Hi there! Yes, I see what you mean. For me, the problem is partly that I
>> think in
>>
>>
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