Hi Mohammed
I don't think your question is naïve, but my answer is.
I think that the most important values are shared, by all humans (maybe all
primates, maybe all mammals, maybe all animals): empathy, fairness,
reciprocity.
We all share, use, and abuse the prosocial values that are (or should be)
the foundation of real EBM, so we should try to understand them and how they
influence our behaviours.
Research evidence can help us understand how differences in values can bind
or divide us. For starters, watch Jonathan Haidt's TED talks.
Your example of the obese patient who prefers bariatric surgery over
lifestyle modifications is a great tool for probing people to discover their
assumptions (e.g. "fat people are self-indulgent sluggards", or "fat people
have a hormonal imbalance") and values (e.g. "I pay my taxes/insurance
premiums and am therefore entitled to my preferred treatment", or "patients
wishes for treatment should only be granted when they are rational and
equitable"). This is what I alluded to when I suggested we need to develop
our skills in the critical appraisal of values. Michael Sandel has a video
on the internet on the values that are lost or subverted when every decision
is based on money. His method is to provide evidence that people are
appalled by something, for example jumping the queue to get healthcare, and
then to work back, or rather, help his audience to work back to see values
have been spiked.
Hope this helps a bit - a full answer would be many lifetimes collaborative
work. So the sooner we start, the better.
m
-----Original Message-----
From: Ansari, Mohammed [mailto:[log in to unmask]]
Sent: 13 January 2014 23:29
To: Michael Power; [log in to unmask]
Subject: RE: Real .v. Rubbish EBM
Dear respected Michael,
One naïve question....
Are all values arbitrary or are some supposedly informed by some higher
principles? If some values are principled, then they too can be
evidence-based in which the "evidence" may not be empiric material evidence
but evidence of reason and logic.
Consider an obese patient who values bariatric surgery over life style
modification.
m
-----Original Message-----
From: Evidence based health (EBH) on behalf of Michael Power
Sent: Mon 13/01/2014 5:00 PM
To: [log in to unmask]
Subject: Re: Real .v. Rubbish EBM
Amy: I like your idea of a visual metaphor, but it needs to be a little more
complicated than a bicycle, because decision-making depends on evidences and
values - both plural. However English grammar forbids us to say "evidences"
because evidence is a mass noun, and mass nouns are so fuzzy that they defy
accurate visualization.
The best metaphor I can imagine is a multi-player computer game in which a
boat is propelled by two parallel banks of rowers, one on the starboard side
and one on the port side - BTW the ancient Greeks took this technology to
the limit with their triremes (http://en.wikipedia.org/wiki/Trireme), which
could have several hundred rowers.
Players (representing values) control the rowers (representing evidences).
Each player can adjust the force and direction of each rower's effort. But,
players (values) are not all equal. And rowers (evidences) are not all
equal. One or two players and one or two rowers will dominate - this
represents our tendency to oversimplify.
The sum of all the rowing efforts determines the boat's direction and speed,
and represents the decision; the final destination represents the outcome.
You can see how a Greek tragedy arises when two powerful values oppose each
other, or a Shakespearian tragedy when a dominant evidence and a dominant
value are not critically appraised - think of Desdemona's handkerchief and
Othello's jealousy - the boat spins out of control and is wrecked on the
rocks.
Ben: your brief history of EBM is useful. But I would suggest that we do not
ignore the parallel movements in improvement (and quality, and safety) and
implementation. EBM can learn from them, and vice versa.
Kev: You are right to wave a red flag over hyperbole that could be
counterproductive if taken outside our debating arena.
Rakesh, Neal, Zbys, Richard: thanks for your comments.
A final suggestion: the way forward could include a step back (in time) to
re-emphasize critical appraisal of evidences, a step forward (in time) to
introduce critical appraisal of values, and another step forward (in
syncopated time) towards the Improvement, Quality, Safety, Implementation
movements.
Michael
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Amy Price
Sent: 12 January 2014 02:25
To: [log in to unmask]
Subject: Re: Real .v. Rubbish EBM
Hi Ben and all,
What if we looked at evidence and decision making like two wheels on a bike?
They both need to be full of substance, well connected, lubricated and
working in balance with a competent driver with good vision on the seat to
get the vehicle where we want it to go? By the same rationale that evidence
is necessary but not sufficient for decision making, values are necessary
and default to feelings based on social pressures and peer influence and
lack focus without evidence and how to apply it. Maybe the bike needs a
check up and a little maintenance to run safely and at optimum performance.
I am hopeful that those who are time and location privileged so they can
attend this open event, will navigate well and come up with insights
together they would not have considered alone. It seems to me that what you
and others have pointed out for some time is starting to take root and
people are exploring ways to grow it out. I know I have considered this
carefully from the beginning after being privileged to enjoy the view from
yours and others experience and expression and I have thought yes I see this
but how can I best take it forward in the trenches. I hope there are more
conversations and collaborations so each one of us that cares can have a
part in the relationship as EBM continues to change health care and
history.Thank you for all you have done, reaching out to those new to the
evidence based way of thinking and your thoughtful papers, much
appreciated.
Yours for evidence with informed decision making!
Best
Amy
From: "Djulbegovic, Benjamin" <[log in to unmask]>
Reply-To: "Djulbegovic, Benjamin" <[log in to unmask]>
Date: Saturday, January 11, 2014 7:19 PM
To: <[log in to unmask]>
Subject: Re: Real .v. Rubbish EBM
In trying to distinguish "real vs. rubbish EBM", have we come a full circle?
Some of us have pointed out for some time now that evidence is necessary but
not sufficient for decision-making. It appears to me that the conference may
end up confusing evidence for decision-making (and vice versa).
Ben Djulbegovic
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Michael Power
Sent: Saturday, January 11, 2014 4:31 PM
To: [log in to unmask]
Subject: Re: Real .v. Rubbish EBM
Hi Ruth
Thank you for the open invitation to your meeting to define real and rubbish
EBM.
If I had been able to attend, I would have offered the points appended
below.
Best wishes
Michael Power
Decisions, evidence, values, going off the rails
· Decision-making is at the heart of EBM, whether real or rubbish.
So, it would be useful to understand what types of decisions we make, and
how we do this.
· EBM decisions are about the health and healthcare of individuals
or of groups. This classification is exhaustive and exclusive, although
guidelines try to span the boundary between groups and individuals.
· All decisions, EBM or otherwise, are made on the basis of both
information (evidence) and emotions. The use of evidence is conscious; the
influence of emotion is usually subconscious. Emotions can outweigh what
rationally seems to be completely convincing evidence.
· Emotions and values are intimately linked. When a decision is in
line with (or contradicts) a value, a corresponding emotion is felt and
guides the response. Values generally are learnt unconsciously and
involuntarily, but can be consciously taught and conscientiously learned.
· Each of us has many different values, some of which are
contradictory, incompatible, or incommensurable. Think of "pro-choice" and
"pro-life". I (hopefully like most people) am for both.
· Most people want to do a good job, but organisations and "the
system" can turn them into robots or petty box-ticking bureaucrats, more
concerned with process than outcomes. A few people are in it for themselves.
Decision-making in Personal and in Public health/care
There are notable differences in the use of evidence and the role of values
between EBM decision making in personal health and in public health.
· Evidence. In public healthcare, statistical evidence from groups
can be confidently used to infer statistical outcomes for groups. But for in
personal healthcare we really want the individual's outcomes, not those for
a population. Bounded rationality (incomplete evidence, imperfect reasoning)
is a particular challenge when practicing personal EBM, because our natural
tendency is to oversimplify. For example, the media tend to report just the
direction of effect: a drug is beneficial (or harmful).
· Values. Values are important in both personal and public EBM, but
we need to be aware of the risk of not taking them fully into account. This
is particularly true for public health (and guidelines), because decisions
are tend to be made on economic values (or non-economic values that have
been monetized without considering what has been lost).
· Guidelines. Guidelines should support real EBM, but can be misused
in rubbish EBM when box-ticking adherence to processes precludes taking into
account relevant personal values and evidence not mentioned in the guidance.
Real vs Rubbish EBM
· Real EBM conscientiously critically appraises and takes account of
all the relevant evidence and all the relevant values in order to support
the patient or policy-maker to optimise their decision-making. Rubbish EBM
does not.
· Clinicians practicing real EBM need to understand, and be able to
communicate to patients, not just the direction, but also the size and
importance of the average outcome (e.g. mean, or median, or mode); the range
of outcomes and shape of the distribution of outcomes (e.g. for cancer
prognosis; the typical long tail after the median); the risks of mistakes,
bias, blindness, and bullshit; and the risk of unknown unknowns (much of the
history of medicine is a series of cautionary tales about unknown unknowns
that should have been anticipated). Rubbish EBM does not do this.
· The values of real EBM are the reflected in a key aspect of EBM
leadership: to recognise an opportunity for improvement, and then to have
the gumption to (responsibly) do something about it. Rubbish EBM does not
see, or ignores opportunities for improvement.
· Clinicians practicing real EBM need to be able to understand,
identify, elicit the relevant values in themselves, their patients, and
their culture. Rubbish EBM does not do this.
· Rubbish EBM prioritises process over outcomes, means over ends,
the practitioner or organisation over the patient. Real EBM has its
priorities right.
The next step: prevention, diagnosis, and treatment of rubbish EBM
Once we have distinguished between real and rubbish EBM, we need to make the
next step, which is to prevent or to diagnose and treat rubbish EBM --- even
if this is not on the agenda for the meeting on the 14th.
Most people want to do a good job, but organisations and "the system" can
turn them into robots or petty bureaucrats, more concerned with process than
outcomes. And, some people when given the opportunity, prioritise their own
advancement (prestige, income, comfort) over the quality of service they
render.
On both sides of the Atlantic, and on either side of the equator, there are
major political and important professional initiatives to change behaviour
in healthcare systems by changing people's values. Generally, the
intervention seems to be a mantra-like repetition of a slogan such as real
EBM, Quality, Improvement, Patients first, Shared decision-making,
Affordable Healthcare, Payment by results, . Theodore Marmor
<http://www.asianscientist.com/books/wp-content/uploads/2013/05/6041_chap01.
pdf> exposed the gap between this type of rhetoric and the reality: the
slogan is presented an effective force for improvement, but serial failures
to meet expectations, far from dampening wishful thinking, simply inspire
senior bureaucrats and policy makers to invent another slogan to promote the
next fad.
Why has so little research on values been done (or at least published in the
types of journals Richard Lehman reviews). Why aren't the following sorts of
question being asked?
· What values do people who wish to practice real EBM need to be
taught, to know, to apply, and to teach?
· What is the optimal way of doing this? What is the role of role
models?
· When someone who originally wanted to practice real EBM develops
into a practitioner of rubbish EBM, what unwanted values have been gained,
and what desirable values have been lost or subverted?
· How can rubbish EBM be prevented, or promptly detected and
treated?
What factors create petty bureaucrats, inhibit responsible innovation,
foster organizational stupidity, promote self-seeking, and allow wilful
blindness and normalization of deviance?
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Ruth Davis
Sent: 09 January 2014 15:45
To: [log in to unmask]
Subject: Real .v. Rubbish EBM
Tuesday 14th January 2014
10:00 -12:30 (Coffee available from 09:30)
Kellogg College, 62 Banbury Road, Oxford
In September 2013 Trish Greenhalgh challenged Carl Heneghan to promote 'real
versus rubbish EBM' on Twitter. An example of rubbish EBM might be (for
example) putting a 75 year old on statins because the guidelines say you
should, with no account of their social situation, comorbidity, life
expectancy etc. Real EBM from a clinicians perspective would include taking
patient values and circumstances into account alongside evidence from
guidelines and from an organizational perspective it would include measures
to avoid a managerialist, technocratic approach to promoting guideline
adherence.
A meeting has been set up in Oxford with the aim is to define real and
rubbish EBM more rigorously. As part of this meeting there will be an open
session for all who would like to hear views on real v rubbish EBM from the
experts.
Spaces a very limited, to register your interest please email
[log in to unmask]
Titles include:
Carl Heneghan - Why most research should not reach the appraisal step
Paul Glasziou - Using healthy skepticism in the patient's interests
Jeremy Howick - A new generation of bias in EBM
Des Spence - EBM as a marketing tool for Big Pharma
Neal Maskrey - It is not real versus rubbish, but EBM versus EBM2
Jon Brassey - An alternative system for systematic review production
Richard Lehman - Patient Centred Evidence - the Unicorn that must be found
Margaret McCartney - Too much treatment for the well, and not enough for the
sick
Mike Kelly - Philosophical reflections on rubbish EBM
Iona Heath - EBM is a means - but to what end?
Ruth Davis
CEBM Centre Manager
Department of Primary Care Health Sciences
University of Oxford
Tel: 01865 289322
Tw: @CebmOxford
www.cebm.ox.ac.uk
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courriel ou son contenu, en partie ou en entier. Si vous avez reçu ce
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