Hi Roy et al,
I've read the paper today and found it readable and pertinent. I've been a
UK GP for a large number of years and work in a deprived inner city, have an
MSc in health sciences and clinical evaluation and have taught EBM. I agree
with the paper, in the UK we have edicts from NICE telling us what to do
with our patients, we are even financially rewarded for measuring all sorts
of things, I am told that I 'should' now be screening diabetics for
depression now (never mind the opportunity cost for what else I could do
with that time), we 'should' be getting blood pressures below this and that,
research papers still distort the truth a) by quoting relative risk
reductions and b) by asking research questions that assume longevity is the
gold standard and b) giving undue weight to confidence intervals bolstered
by the internal consistency of the paper's stats, and c) assuming that just
because a risk can be calculated that it is somehow accurate when we know
that's a myth.
Maybe most doctors just like to be told what to do and to be given a cookery
book of recipes to follow. In my experience of teaching primary care doctors
and nurse how to calculate risk, this isn't something they will do in the
course of routine work, they just want to be told who to prescribe what to.
They have often in fact stopped thinking about what they are doing.
The public health specialists I've spoken to don't see individual risk
communication as important, "Thats your problem" they say to me, a GP.
Eminent epidemiologists have hailed the concept of the 'polypill' ignoring
the implication that the majority of the over 40s will be pathologised and
labelled as 'ill', with false expectations of what medicine can deliver
fostering dependence, the EBM movement has embraced and imposed colonic
cancer screening but the papers have inadequately measured changing health
beliefs and the emotional adverse effects .
I accept that EBM and the controlled trial has achieved a huge amount
especially in therapeutics, but I suspect the current mania for
'preventitive' treatment and screening is doing more harm than good in
preventitive medicine terms, and I am keen to avoid doing harm.
I agree with the paper that the discourse of EBM is 'dominating' with its
moral overtones, and that this does actively discourage and exclude
alternative views, and the term fascism may feel nasty because of its
historical connotations but I feel it is in fact justified.
It feels especially healthy to have these sort of ideas aired, I feel they
should be taken seriously. Just read a few of the editorials in the BMJ,
look closely at the language and the way its coercive intent on clinicians.
This paper in fact feels overdue.
As a way forward, I think we should take a step back, research findings
should be presented more neutrally, the adverse effects of screening for
example should be explored in more depth, family practitioners should have
more freedom to decide for themselves what treatments feel worthwhile
without being incentivised to follow the rule of EBM edicts like sheep, we
should enable and introduce more variability and innovation not seek to
remove it.
Owen
Owen Dempsey
GP
----- Original Message -----
From: "Roy Poses" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, August 23, 2006 4:21 PM
Subject: Fwd: RE: Deconstructing the evidence-based discourse in health
sciences
I now have actually read the paper below, a very painful process.
The issue is not "elaborate" language, although the paper is written in the
usual turgid post-modernist style, with all the expected bowing and
scraping to Foucault, Derrida, Lyotard, Deleuze, Guttari, etc, the tortured
sentence structures, and the obscure ("interpellated"), and sometimes
made-up words ("hysterisation").
The paper makes some accusations which in a way are hilarious. In my
personal experience, it has been hard to get EBM related concepts into
medical education, and to get funding for EBM related scholarly work. Yet
Holmes et al accuse EBM of being so powerful that "in a number of faculties
of health sciences ... the dominant paradigm of EBHS [evidence-based health
science] has achieved hegemony." I have never seen such an
institution. Instead, in most medical schools that I have seen, EBM
advocates are a minority, sometimes embattled. Holmes et al also asserted
that EBM advocates get "institutional promotions and accolades, public
recognition, and state contracts of all kinds." Huh? Boy, I sure have
missed out, and so have many of my friends and colleagues. (To add further
irony, Holmes at all sort of got one of those "state contracts of all
kinds." Their paper was funded by the Canadian government, through the
Canadian Institutes of Health Research- Institute of Gender and Health.)
But the paper goes from hilarious to nasty (which is why I don't believe
that it was a hoax or a parody). The paper literally accuses advocates of
evidence based health of being fascists, and accuses the Cochrane
Collaboration of being a fascist organization, "The classification of
scientific evidence as proposed by the Cochrane Group thus constitutes not
only a powerful mechanism of exclusion for some types of knowledge, it also
acts as an organising structure for knowledge and a mechanism of
ideological reinforcement for the dominant scientific paradigm. In that
sense, it obeys a fascist logic." Furthermore, "fascism is not too strong
a word because the exclusion of knowledge ensembles relies on a process
that is saturated by ideology and intolerance regarding other ways of
knowing." (Read the paper, if you can stand it, to find many more examples
beyond these quotes.)
A final thought ... This paper suggests another possible explanation of why
academic health care institutions have been so ineffective in challenging
some of the real threats to our professional values (of the sort we have
documented on Health Care Renewal, http://hcrenewal.blogspot.com/) Perhaps
they have been distracted by post-modernism's incomprehensible word-play,
cults of personality, and now its wild accusations against EBM, one of the
only movements which tries to determine what really works in health care,
unbiased by commercial and ideological concerns. Then the question arises:
Has post-modernism been deliberately encouraged by some academic leaders,
possibly those with the most severe conflicts of interest, to distract us
from concentration and abuse of power in health care, the pervasiveness of
conflicts of interests in health care organizations, and unethical and even
illegal behavior by health care leaders?
>Dear All,
>well, the language is elaborate, but the ideas aren't really that
>outrageous. They seem to be saying that any group defines and promotes what
>it considers are norms for behaviour/thinking etc. and this inevitably
>excludes certain ways of doing things which can unwittingly have
>disadvantages. I think many EMBers are well aware of this.
>Michael
>
>
>-----Original Message-----
>From: Evidence based health (EBH) on behalf of Roy Poses
>Sent: Mon 8/21/2006 4:51 PM
>To: [log in to unmask]
>Cc:
>Subject: FW: Deconstructing the evidence-based discourse in health
>sciences
>
>(Sent with apologies to my good friends and colleagues at the University of
>Ottawa who have been steadfastly been aiding the development of
>evidence-based medicine.... These colleagues had nothing to do with the
>paper mentioned below....)
>
>The following email has been circulating.
>
>It describes a mind-bendingly post-modern paper, published in a seemingly
>respectable health care journal, which likens proponents of evidence-based
>medicine to fascists.
>
>The paper is real, and is available on the web. The abstract below is
>representative. As best as I can tell, the paper was not a hoax of a
>satire.
>
>It seems to be an example, albeit perhaps isolated, of where the march of
>post-modernism in academia may lead....
>
>
> >>This (link to pdf below) is a recent paper which I first took to be a
> >>hoax.
> >>Apparently they are serious...
> >>
> >>Newspeak rating: Doubleplus ungood.
> >>
> >>"Deconstructing the evidence-based discourse in health sciences: truth,
> >>power and fascism"
> >>- Dave Holmes RN PhD,1 Stuart J Murray PhD,2 Amélie Perron RN
> >>PhD(cand)1 and Geneviève Rail PhD1
> >>1 Faculty of Health Sciences, School of Nursing, University of Ottawa,
> >>Ottawa, and 2 Department of English, Ryerson University Toronto,
> >>Ontario,
> >>Canada.
> >>
>[snip]
> >>http://www.ucl.ac.uk/Pharmacology/dc-bits/holmes-deconstruction-ebhc-06.pdf
> >>Or:
> >>http://tinyurl.com/fdbry
> >>
> >>Some comments on this paper-
> >>The Quack Page (under 'worse than Barry'):
> >>http://www.ucl.ac.uk/Pharmacology/dc-bits/quack.html#holmes1
> >>badscience.net:
> >>http://www.badscience.net/?p=277
> >
>
Roy M. Poses MD
Clinical Associate Professor
Brown University School of Medicine
<[log in to unmask]>
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