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As a Canadian Geriatrician who routinely sees the families you describe at the end of your message AND one who practices EBM, I feel with you about your frustration with EBM. The EBM answer - there is none, as no one has studied this population for this indication. However, using John Dall's findings of efficacy of antihypertensives in the over 80 crew and similar other findings for beta-blockers in CHF, I would have to extrapolate and say that the role of slowing down progression of the Multi-infarct dementia with statins is possible and biologically plausible. There is a potential argument about dosing (see Paula Rochon's articles on dosing) That is only expert opinion, however. In the end, the real issue is that the family is grieving, and is having difficulty discussing limits to treatment. They are not presently able to hear what you are saying. They may never be able to hear it. In any case, you have my commiseration, sympathies and good wishes in managing this patient(s). ----Albert -----Original Message----- From: Evidence based health (EBH) is the integration of individual knowledge [mailto:[log in to unmask]] On Behalf Of Adrian Freeman Sent: Wednesday, May 08, 2002 4:34 PM To: [log in to unmask] Subject: FW: How do various specialities view EBM? -----Original Message----- From: Adrian Freeman [mailto:[log in to unmask]] Sent: Tuesday, May 07, 2002 12:21 To: Greener, Jenny Subject: RE: How do various specialities view EBM? This is the point where we have the challenge and excitment of practising medicine. I am speaking as a UK GP. My focus is completely on the level of the individual patient. For that patient I am balancing the evidence for a particular service against their needs and wants. I have to help them to interpret the evidence and more often than not the robustness of any evidence for that individual patient sharing their health with me is poor. I know that globally resouces should be husbanded to provide for example more hip replacments. However the quality of life for that individual patient could be enhanced considerably by public money paying for an intervention with some evidence but not totally robust. It is a wonderful challenge to use EBM appropriately. As a doctor I feel uncomfortable refocussing away from the level of the individual patient. And yet I know the needs of society, I know that evidence is based on a scientific and robust methodology. I also know that the patient in front of me might have been excluded from any robust trial because of their multiple pathology, poor compliance and just being a struggling human being who could not fit into a controlled and scientific research protocol. By the way, I am too busy/lazy to find out, what is the evidence for prescibing statins in a patient in their 80s with known ischaemic heart disease, previous CVA, with residual paralysis and multi infarct dementia resident in a nursing home with caring relatives who want everything to be done for their mother? If the answer is no statins then start removing one at a time each of the above descriptors. Dr Adrian Freeman MMedSci, FRCGP -----Original Message----- From: Evidence based health (EBH) is the integration of individual knowledge [mailto:[log in to unmask]]On Behalf Of Greener, Jenny Sent: Monday, May 06, 2002 01:24 To: [log in to unmask] Subject: Re: How do various specialities view EBM? How about refocussing the question away from the level of the individual patient - if there is no robust evidence of effectiveness for a particular service, should public money continue to pay for it?- perhaps a question of particular relevance in the UK NHS context. Jenny -----Original Message----- From: Stephen M. Perle, DC [mailto:[log in to unmask]] Sent: Thursday, May 02, 2002 5:49 PM To: [log in to unmask] Subject: Re: How do various specialities view EBM? Unfortunately you did not answer my question. I ask a genuine question and your response is flippant.. I know it is an anecdote, but if what I do is only placebo, how do I rationalize experiences like the one related? Does it seem likely that this was a placebo response? Doesn't placebo response require the patient to believe that the placebo is or could be effective? I understand what the literature tells us about the effectiveness of what I do. I know that at best it is equivocal and thus one must use their own judgment when confronted with a patient in pain. Isn't our current state of knowledge when it comes to the treatment of low back pain such that the evidence for any treatment is poor? So should I say to the patient, "You know research has not definitively found any treatment to help so suffer?" Obviously, the anecdote (which I know holds no probative value to the world of science) is my experience, thus it colors my judgment and pushes me off the fence to decide that lacking more definitive research I shall continue to use my best judgment and treat patients with the tools at my disposal. I say instead to the patient let's try a trial course of treatment and see if you respond. Is this not what Sackett (1) means when they say EBM is the best available external evidence, patient's desires and *doctor's expertise*? Or did I miss the meaning of doctor's expertise? 1. Sackett DL. Evidence-based medicine [editorial]. Spine 1998;23(10):1085-6. preston wrote: > Unfortunately you offer a typical response, nice anecdote! > > > I always tell my students that when you treat a patient and they > > feel better > > *after* they have left the office, they should always question was > > this placebo or natural history. But when one sees instantaneous > > responses I have less belief it is natural history but it could > > still be placebo. > > > > So from my personal experience let's look at a low back pain patient where > > the literature is much more equivocal. The patient barely walks > > into my office. I mean they walk bent over with their hands on > > their thighs to help > > hold up their body. They are obviously in extreme distress They have been > > suffering for two weeks with no change in Sx. They saw their M.D. > > and had > > both Rx NSAIDs and muscle relaxers which have had absolutely no > > effect. A > > friend twists their arm and makes them come to see the quack, er I > > mean, the > > chiropractor. I examine the patient and give them one manipulative thrust > > and concurrent with the thrust they are instantly pain free. (BTW > > this is > > an example of a relatively common occurrence) If this is a placebo, > > why didn't the medication work as a placebo? Why is the placebo a > > treatment that they absolutely did not want because they knew it > > would not work? Aren't placebo effective because the patient > > BELIEVES it will work? -- _____________________________________________________________________ Stephen M. Perle, D.C. Associate Professor of Clinical Sciences University of Bridgeport College of Chiropractic Bridgeport, CT 06601 www.bridgeport.edu/~perle _____________________________________________________________________ Ignorance more frequently begets confidence than does knowledge: it is those who know little, and not those who know much, who so positively assert that this or that problem will never be solved by science. Charles Darwin