Hi
I apologise for cross-posting. I think that there are many interesting aspects of EBM that are still waiting to be put into practice that would fill many of the gaps that admittedly exist.
There are methods for creating evidence based diagnostic criteria, EB treatment criteria, EB differential diagnoses, personal evidence based records of individual patient care, etc. All this will be central to 'personalised' and 'stratified' medicine.
Personal evidence based records and summaries of individual patient care specify which of that individual patient's symptoms and other findings (ie 'personal' evidence) were used to apply published evidence from groups of patients in the literature (eg RCTs). Such patient records would also be a powerful tool for doing further studies.
It is important to bear in mind that there are two kinds of thinking in medicine and other walks of life:
1. Intuitive subjective imaginative non-transparent reasoning that allows doctor to work quickly but also throws up new ideas (Kahneman calls it 'fast' thought).
2. Transparent thought is used to check non-transparent thought and to persuade colleagues verbally and in writing to agree. Whenever possible it is grounded in evidence. Kahneman calls this 'slow' thinking.
Many who work alone only use non-transparent thought with all its risks. Doctors who work in teams frequently use transparent thinking and this highlights errors in non-transparent thought as well as gaps in evidence.
If EBM widened its horizons it would prosper greatly and help solve many current problems in medicine to the great benefit of patients.
Huw Llewelyn
Consulant physician in endocrinology, general and acute medicine
Hon Fellow in Mathematics
Aberystwyth University
-----Original Message-----
From: "[log in to unmask]" <[log in to unmask]>
Sender: "Evidence based health (EBH)" <[log in to unmask]>
Date: Fri, 25 Oct 2013 18:15:33
To: <[log in to unmask]>
Reply-To: "[log in to unmask]" <[log in to unmask]>
Subject: Sv: Re: Criticisms of EBM
Hi!
Does anybody know of somebody who has tried to assess an effect EBM (whatever
the definition of EBM), or plans to do such a study?
EBM adherents: Show your weight!
As for myself, EBM is like one of the famous saga's by the Dane H.C. Andersen
(printed more than a hundred years ago.
I will do my best to put down my own and others' contemplated reflexions on
this important topic.
I am serious!
//Bengt
>----Ursprungligt meddelande----
>Frċn: [log in to unmask]
>Datum: 2013-10-25 06:01
>Till: <[log in to unmask]>
>Ärende: Re: Criticisms of EBM
>
>Hi Anoop,
>
>I have seen this all before and first of all it is an unbalanced picture of
>what EBM is and does and I think deliberately so. Epidemiology is not true
>or false it is one system used for solving problems and evidence based
>medicine requires finding the best available evidence for your patient. EBM
>is bigger than epidemiology and does not depend exclusively on this field
>even though it is important. This movie gives no place for Equator
>guidelines, GRADE or even mixed methods research, it is just throwing rocks.
>We all know and people on this board have co-written papers on how in a very
>short span a large proportion of medical practice becomes obsolete as
>greater knowledge replaces outdated treatment and diagnosis. To lump EBM
>with insurance companies, opinion leaders and by implication pharma is a
>very inaccurate stretch of literary license.
>
> I find this rhetoric is high on justifying someone doing their own thing
>and calling it 'practice or art of medicine' rather than putting
>innovations and new research questions through the paces to find out if they
>are indeed safe and effective. People are deceived because they are wowed
>by statistics and percentages because math is not their friend. Notice there
>is no discussion of NNT NNH RR or even background of the intervention with
>the appropriate values. I would learn more reading the National Inquirer or
>the Daily Mail and at least then they would have coupons or some other
>little return for giving them my attention. I did a little article on EBM
>here http://www.ithinkwell.org/what-is-real-ebm/
>
>People die because of the sloppy practice of medicine and inaccurate maths
>along with trial results unregistered and unreported. This is also a form
>of sedition because it turns the common people against regulators like the
>FDA who are there to protect them and the people have no way of knowing what
>medicine is like in the countries where it is unregulated. Hint, people die
>and lose function because the lessons of ethics, research and epidemiology
>go unheeded. Watched it happen consistentlySthat is why I ended up taking
>evidence based health care. The carnage and collateral damage from bad
>medicine does not bring people freedom it delivers death and deception.
>
>Best,
>Amy
>
>From: Anoop B <[log in to unmask]>
>Reply-To: Anoop B <[log in to unmask]>
>Date: Thursday, October 24, 2013 10:51 PM
>To: <[log in to unmask]>
>Subject: Re: Criticisms of EBM
>
>Here are some more of his comments:
>
>A short translated summary on the movie of Yvo Smulders
>Conclusions:
>- Epidemiological evidence is over appreciated
>- there are other, equally important sources of evidence than
>epidemiological evidence
>
>This is leading to a overkwalification of : ³thereıs no evidence for that S
>(diagnostic tool / therapy / etc) ² This overkwalification of ³unfounded² is
>done by collegues, medical opinion leaders, government, insurance companies,
>etc.
>Epidemical evidence shouldnıt be the norm, because:
>- It is in many cases unavailable / not-existing
>- Often ³false²
>- Only occasionally external valid to the patient
>- It isnıt the critical factor in ³good healthcare².
>Only of 36% of the major / usual therapeutic interventions is benificial or
>likely tob e benificial.
>8% is a trade off, between benefits and harms, 6% unlikely to be benificial,
>and 4% is likely to be ineffective or harmfull. 46% there is no conclusive
>evidence. This is just about interventions, not prognostics, diagnostics,
>etc. etc.
>Cardiology guidelines, total guideline only has 11% level a recommendation,
>and of the class a recommandations only just under 20% level A evidence
>based. Weıll probably never close the gap.
>A lot of bias is present in epidemiological evidence.
>There is methodological evidence.
>example SSRIıs: Sponsored studies show many benefits, non-sponsored is about
>50-50, a lot of negative studies werenıt published.
>If you take all estimated bias in account you might do an educated guess on
>how true epidemiological evidence is (this is different from p-values): huge
>RCTıs and metareviews of large RCTıs 85% true; all others are below 50% true
>Even if you consider epidemiological to be true, the best case scenario is
>that epidemiological evidence is external valid in 40% of the patients with
>a complaint, in the worse case scenario that is 0,001%
>Thus, all-and-all it is pretty weak:
>1/3 is studied
>1/2 is true
>It is only external valid to 10% of your patients
>You probably donıt know more then 50% of all relevant evidence
>THUS 1/120 of your therapeutic actions are based on evidence!
>If you compare hospitals who score high on quality care, vs. Hospitals who
>score low on quality of care, the critical factor does not appear to be EBM
>on epidemiological studies. The critical factor seems to be the fact that
>the better hospitals are known for their a good ³culture² (literally: ³soft
>variables²)
>On accountability: Only 4% of the medical mistakes are duet o shortcommings
>in knowledge. Rest is clinical reasoning, lack of commitment, lack on
>communication.
>
>
>
>On Thu, Oct 24, 2013 at 10:43 PM, Anoop B <[log in to unmask]> wrote:
>> Thanks Andy and David for your thoughts!
>>
>> Alex, also how delayed the research gets accepted and practiced. The
>> corticosteroid administration for premature babies is a good example I
feel.
>> The systematic review came out in 1981, but it was only routinely
practiced
>> after the NIH consensus statement in 1994! So we had the knowledge, but
didn't
>> translate into practice for reasons you cited. And thanks for the link.
How
>> people make decisions and learn is very fascinating and goes to the root
of
>> the problem, I feel.
>>
>> And I can understand all his criticisms. But I do hope he is not
suggesting
>> hence let's throw out EBM. My point is we can have all the criticisms, but
is
>> there a better alternative? No.
>>
>>
>> On Thu, Oct 24, 2013 at 9:18 AM, David Braunholtz <[log in to unmask]
com>
>> wrote:
>>> I don't speak Dutch either, and have no idea where the numbers come from
or
>>> if they are reasonable. However (as Yvo may very well have pointed out
>>> somewhere in his talk, before the clip) the evidence in EBM should not be
>>> thought of as just RCTs (or lesser comparisons) of therapies. If that is
what
>>> he means when referring to 'epidemiological evidence', he may have an
point:
>>> ie HSR (health services research) may be more important. HSR is
essentially
>>> about behaviours and systems, a much more difficult area to gather
'evidence'
>>> which will help design good interventions, as behaviours are complicated,
and
>>> (in my opinion) useful HSR evidence really is about reaching a good
>>> understanding of 'what is going on & why' (ie developing and testing
theory).
>>> NB this is in contrast to testing effectiveness of a drug in a patient
group,
>>> no knowledge of mode of action required !
>>>
>>> So Yvo would presumably support research and gathering of evidence (ie
>>> understanding) on how to improve clinical reasoning, commitment,
>>> communication, and other 'soft' variables ?
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>> On Thursday, 24 October 2013, 13:35, Anoop Balachandran
>>> <[log in to unmask]> wrote:
>>>
>>>
>>> Does anyone have any comments on Yvo Smoulders criticisms of the EBM
>>> approach.
>>>
>>> http://www.youtube.com/watch?v=PRiSlU1ucqI
>>> "
>>> I don't understand Dutch so I couldn't find out where he got most of his
>>> numbers. Some of his numbers ,like "only 4% of the medical mistakes are
due
>>> to shortcomings in knowledge" seem to be a bit far fetched.
>>>
>>> Some if his commented translated by another person:
>>>
>>> "Even if you consider epidemiological to be true, the best case scenario
is
>>> that epidemiological evidence is external valid in 40% of the patients
with a
>>> complaint, in the worse case scenario that is 0,001%
>>> Thus, all-and-all it is pretty weak:
>>> 1/3 is studied
>>> 1/2 is true
>>> It is only external valid to 10% of your patients
>>> You probably donıt know more then 50% of all relevant evidence
>>> THUS 1/120 of your therapeutic actions are based on evidence!
>>> If you compare hospitals who score high on quality care, vs. Hospitals
who
>>> score low on quality of care, the critical factor does not appear to be
EBM
>>> on epidemiological studies. The critical factor seems to be the fact that
the
>>> better hospitals are known for their a good ³culture² (literally: ³soft
>>> variables²)
>>> On accountability: Only 4% of the medical mistakes are duet o shortcomings
in
>>> knowledge. Rest is clinical reasoning, lack of commitment, lack on
>>> communication."
>>>
>>>
>>>
>>>
>>>
>>
>
>
>
>
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