1) I would definitely agree w/ Amit that Guyatt,
Sackett, Ebell, Slawson and a few others over the past
15 years have been groundbreakers in leading us to
think about how we think about evidence. My earlier
post was intentionally simplistic - just putting out
the VERY basic version of how I describe EBM to
students - but not intended to overlook the major
advances in thinking about critical appraisal we've
seen in the past decade or so.
2) Also agree that, as with many things, the promise
some perceived that EBM would "answer all our
problems" (if that promise was ever there) was
overstated. It's one thing to know we need evidence,
it's entirely different to a) FIND the evidence, and
b) APPLY it.
3) Part of the reason I DO like to describe evidnece
as everything from individual, unsystematic
observations all the way up to systematic
meta-analyse, however, is that I think it gives us
(and learners, in particular) spectrum on which to
place all the clinical thinking we do that is NOT
informed by high-quality RCTs, meta-analyses, etc.
That is, since we know that there is a paucity of
high-quality evidence to answer clinical questions,
and since we also see in all our colleagues the
aplication of clinical experience, I think it is
useful to have a spectrum on which we can organize our
thinking about how all sorts of levels of quality of
evidence fit together.
4) Another helpful article by Ebell (again, use this a
lot w/ students) is an editorial that addresses some
of the recent changes in medical thinking that have
come out of increasing EBM scrutinty (eg, Vitamin E,
COX2s, HRT) - see
http://www.aafp.org/afp/20050601/editorials.html
Enjoying the discussion!
Bill C
--- "Ghosh, Amit K. M.D." <[log in to unmask]>
wrote:
> I do agree with Bill on his excellent analysis.
> However I would like to add that till the Sackett
> and Guyatt's introduction of the discipline of EBM I
> am not sure if we did look into studies as
> critically as we do now.
> Medical curriculum was deficient in this aspect and
> even now in many places only catching up.
>
> The bigger question remains whether teaching the
> basics of EBM would be an answer to all the problems
> when the physician has little control on anything
> else. The over simplistic way to think is that
> critically reviewing an article would provide the
> best evidence for the patient( we don't make that
> promise any more). The issues surrounding successful
> implementation of EBM in medical schools are far
> more complicated with mega secondary sources of
> information like UpToDate and others coming to the
> physicians rescue more frequently than the
> complicated juggernaut of negotiating the 4 S model
> ( systems, synthesis, secondary sources, studies).
> In all fairness despite it great precision and
> depth, Cochrane reviews are hard to digest in the
> time that any practitioner will ever have( average
> review is 50 pages ).
> The final blame always falls in our inability to
> fulfill the promise that many of us make that
> teaching EBM will it solve most the problems.
> In all its simplicity and complexity EBM has
> unraveled a whole set of issues confronting medical
> education and medical practice and we thank the
> McMaster Group for this step forward. How we finally
> use EBM in an uniform fashion, all around the globe
> remains the experiment for the near future.
>
>
> Amit K. Ghosh, MD, FACP
> Associate Professor of Medicine
> Associate Program Director,
> General Internal Medicine Research Fellowship
> Mayo Clinic College of Medicine
> 200 First Street SW
> Rochester, MN,
> USA 55905
> Phone : 507-538-1128 (Clinical)
> 507-284-4967 (Administrative)
> Fax: 507-284-4959
> Email: [log in to unmask]
>
>
> -----Original Message-----
> From: Evidence based health (EBH)
> [mailto:[log in to unmask]] On
> Behalf Of Bill Cayley, Jr
> Sent: Friday, June 30, 2006 8:26 AM
> To: [log in to unmask]
> Subject: Why is EBM Important?
>
> Here's my answer - along the lines of the
> introduction
> I give our medical students:
>
> In medicine, we are continually making decisions,
> and
> if medicine is to be a science or a "learned"
> profession, we need to think critically about HOW
> and
> WHY we make those decisions. There are a number of
> potential approaches to making decisions: 1)
> Tradition
> ("we've always done it this way", "my teachers did
> it
> this way"); 2) Convention ("everyone else always
> does
> it this way" - ie, going with the crowd), 3) Belief
> or
> Dogma ("I believe the natural way is best"), 4)
> "Evidence-based" - that is based on some sort of
> systematic assessment of evidence.
>
> Further, I discuss with my students the fact that
> you
> can look at evidence as simply ANY observation about
> the nature of the world. In the medical literature,
> we
> call a single, isolated instance of something an
> "anecdote" (or, if published, a "case report"). If
> you take a bunch of observations and group them
> together, we have a "case series". You can go on up
> from there in terms of the rigor, systematization,
> and
> thoroughness of evidence evaluation up to the
> double-blinded randomized trial or the
> meta-analysis.
> ALL observations can be considered "evidence" - it's
> just a matter of asking what the QUALITY of your
> evidence is.
>
> So, I see evidence-based medicine as the effort to
> critically examine the reasons we do what we do, and
> the information or evidence that supports it. In one
> sense, ALL medicine is "Evidence-Based Medicine" -
> it's just that if you practice medicine without
> thinking critically about what you do and without
> looking for high-quality evidence (or at least the
> highest quality available) then you are practice
> medicine based on very LOW-quality evidence.
>
>
> Bill C
>
>
>
> --- Olive Goddard <[log in to unmask]>
> wrote:
>
> > Dear Colleagues,
> >
> > Here's a question some of you might like to
> respond
> > to.
> >
> > All good wishes,
> >
> > Olive
> >
> > >>> "Gang Jiang" <[log in to unmask]>
> > 29/06/2006 16:16 >>>
> >
> > Dear Sir/Madam:
> >
> > I am very interested in evidence based medicine.
> > Could you please tell
> > me why EBM is important? Can a physician practise
> > medicine without
> > knowing EBM?
> >
> >
> > Thank you,
> >
> > Gang Jiang
> >
>
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>
>
> Bill Cayley, Jr, MD MDiv [log in to unmask]
>
> Augusta Family Medicine Home Address
> 207 W Lincoln 3433 McIvor St
> Augusta, WI 54722 Eau Claire, WI 54701
> Work: 715-286-2270 Home: 715-830-0932
> Page: 715-838-7940 Cell: 715-828-4636
>
Bill Cayley, Jr, MD MDiv [log in to unmask]
Augusta Family Medicine Home Address
207 W Lincoln 3433 McIvor St
Augusta, WI 54722 Eau Claire, WI 54701
Work: 715-286-2270 Home: 715-830-0932
Page: 715-838-7940 Cell: 715-828-4636
