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I am in agreement with much of what has been said about the Holmes et al paper - it has a cavalier attitude towards making sweeping statements based on tenuous evidence, and (problematic though such research may be) the apparent unwillingness to conduct methodologically rigorous research on (e.g.) the Cochrane Collaboration does not help their case. Despite all this, I still think that Michael has a point when he says that "the ideas aren't that outrageous... any group defines ways of doing things that excludes others" - maybe this is at the root of the authors' use of the word 'fascist' - they had gotten fed up not being listened to, and thought that courting controversy might be the best option for stimulating debate about the issues concerned (and perhaps it has worked, going by the postings on this and the Evidence Network mailing lists!) I would like to ask some of the other members to elaborate a little more on their postings if possible, in the main because it seems that their experiences of EBM are so polarized that I have trouble reconciling them. Roy states that he has found it "hard to get EBM related concepts into medical education [and] funding for EBM work", whilst Owen states that his involvement with the education of primary care Doctors and Nurses has been notable for its production of practitioners who "just want to be told who to prescribe what to". I think what Owen is getting at here is that despite EBM's ideal of integrating diverse forms of knowledge (research evidence, Doctor's experience, patient's values), the effect has been to produce practitioners unable to think. Yet Roy is concerned that EBM concepts have not affected the practice of medical education enough! In response to Michael (Power), who criticises the rationale in the paper for stating that "98% of literature is deemed scientifically imperfect". Yes, there are some research questions that can only be rigorously answered using a particular method, but there are also many that require the melding of knowledge from a number of different methods in order to be adequately answered. In my own research in Public Health at NICE, broadly stated it may be said that there is concern from the expert committees about (and a somewhat lethargic institutional recognition of) the 'whittling away' of research on the basis of a hierarchy of evidence, only to be left with 1 or 2 RCTs (out of an initial 1000+ citations) upon which to formulate guidance. Is this a justifiable state of affairs, or should there be less 'severe' exclusion criteria so that valuable evidence can be gleaned from 'less rigorous' studies? Mark Pearson School of Law and Social Science University of Plymouth 20 Portland Villas Drake Circus Plymouth Devon PL4 8AA ________________________________ From: Evidence based health (EBH) on behalf of James Woodcock Sent: Thu 24/08/2006 11:26 To: [log in to unmask] Subject: Re: Deconstructing the evidence-based discourse in health sciences) Michael, I think you are too harsh on deconstructionism. Any method can be used badly. I think it is noteworthy that their article was not published in a sociology journal, my guess is that it would not have been accepted. James Roy, thanks for bring this paper to our attention. I wonder how the authors (and their supporters) would feel sitting in a court where the only "evidence" allowed was accusations and testimony by their enemies. This is how fascism works, and this is how Dave Holmes RN PhD, Stuart J Murray PhD, Amélie Perron RN, PhD(cand) and Geneviève Rail PhD judge evidence-based healthcare. To justify this assertion I shall deconstruct one of their deconstructions. They say "For example, one of the requirements of the Cochrane database is that acceptable research must be based on the RCT design; all other research, which constitutes 98% of the literature, is deemed scientifically imperfect." The supporting citation is not to the Cochrane Library or Manual of systematic reviews, but to "Traynor M. The oil crisis, risk and evidence-based practice. Nurs Inq 2002; 9: 162-9." By relying on bigoted and uninformed testimony rather than evidence they demonstrate a fascist disdain for the truth. They also demonstrate a common psychological failing: seeing your own faults magnified in other people. Similarly, to talk about "the Cochrane database" in this way demonstrates their ignorance of what the Cochrane Collaboration does. The Cochrane Library has about 6 databases or registers (counting is problematic because it is difficult to tell from the website whether a "product" is a separate database or a filtered view of a larger database). If they wanted to refer to the register of controlled trials they should have said so. But, if they had done this it would have exposed the wooliness of thinking in the accusation that 98% of the scientific literature is imperfect. Putting in the number "98%" demonstrates another common psychological failing: when you are insecure, throw in a few pseudofacts to cover your ignorance. Have they (or anyone else) tried to count "all other research"? My final deconstruction (I could go on, but it would be pointless) is to note the scope of the accusation that "98% of the literature is deemed scientifically imperfect". Holmes et al conveniently do not answer the question "Imperfect for what?". If it had occurred to them that this is an important detail they would have soon realized that science has a large toolbox of study methods, and good scientists use the appropriate tool for the job. Only a deconstructionist could imagine that an RCT would be used to assess the management of avian flu in a particular country. An observational study is needed. Deconstructionists avoid details and facts because they impair their ability to insinuate, slur and slander, and because this might highlight the absence of constructive criticism. This is a pity, because there is much room for improvement in the aspirations, rhetoric and practice of evidence-based healthcare. It is a double pity because people who are aware of the shortcomings of evidence-based healthcare too easily accept fascist-style judgements about evidence-based healthcare. Deconstructionism is fascist surrealism. Michael ======================== Michael Power MD Clinical Knowledge Author, Guideline Developer and Informatician Prodigy Knowledge http://www.prodigy.nhs.uk/ ______________________________________________________________________ This email has been scanned by the MessageLabs Email Security System. For more information please visit http://www.messagelabs.com/email ______________________________________________________________________ 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