Dear Llwelyn,
Many thanks for your reply. Please, tell me if you know of any studies of the
efficacy/effectiveness of EBM. And, do you have any ideas about how to assess
it's value?
Best,
Bengt
>----Ursprungligt meddelande----
>Från: [log in to unmask]
>Datum: 2013-10-25 23:00
>Till: "[log in to unmask]"<[log in to unmask]>, "EVIDENCE-BASED-
[log in to unmask]"<[log in to unmask]>
>Ärende: Re: Criticisms of EBM
>
>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----
>>Från: [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 : ³there¹s 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 shouldn¹t be the norm, because:
>>- It is in many cases unavailable / not-existing
>>- Often ³false²
>>- Only occasionally external valid to the patient
>>- It isn¹t 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. We¹ll probably never close the gap.
>>A lot of bias is present in epidemiological evidence.
>>There is methodological evidence.
>>example SSRI¹s: Sponsored studies show many benefits, non-sponsored is
about
>>50-50, a lot of negative studies weren¹t 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
>>RCT¹s and metareviews of large RCT¹s 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 don¹t 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 <david.
[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 don¹t 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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