Dr Poses,
Interesting mailing, if abrasive, closed, and narrow. EBM in reality is not
taking into account 'experience' or context etc, at least not in UK primary
care. We do need to take a more objective view of EBM, as it is being
practiced, and abused.
You would think that given the harm medicine has done over many generations
(qv HRT, (and other examples you can quote better than me) that its
practitioners would be prepared to listen and engage constructively with
criticism. I don't care whether you, as an individual, do or not (listen
that is), I object to the presumptious: 'my worldview is the ONLY way'
stance you seem to take. Perhaps tolerance and an attempt at dialogue mght
be a better way, maybe these authors have something to teach us, given some
encouragement.
Look at the words you use: and their implications
'taking another whack'
these people clearly see EBM baiting as an immature game for their own
selfish pleasures
'Accusations'
Who is accusing you
What are they accusing you of?
Have you done somebody some wrong
Does some retribution need to be sought
If so, what do you have in mind
Why have they done what they've done
(Have you asked yourself that?)
'Here we go again'
we've already completely demolished these arguments before, and i'm getting
tired of this game
(there is no room for dialogue - an aggressive stance)
'thanks to a tip'
this was being kept secret from us ( our little cabal) but we have spys
'the now familiar attributes'
how boring to re visit this nonsense, from idiots, less intelligent than us
'diatribe'
can't be bothered to look this up to be honest
'the apparently deliberate obscurity of these arguments'
they must be a devious lot
my comments:
in reality ebm is being taken over, in the uk by 'the money', govt, and
public health to re-define good practice, clinical experience is actually
counting for nothing - 90% of 20 salaried GPs in a session today thought
that guidelines and financial incentive to use 'depression scores' actually
diminished quality of care (not published) - the other 10% seemed to like
the money (or are intimidated by their bosses).
to simplify, my colleagues in general practice are labouring under an
assault of 'practice' must-dos, from government, in the name of EBM, that
are not evidence based at all. Personal experience, empathy, caritas, are
being sidelined in favour of public health approaches, drug company profits,
government votability, GP profits and shiny cars.
Beware: I love good evidence, I understand its limitations, it is being
abused.
I would call on people to a) try to engage with people who have clearly
thought through the damage the abuse of EBM is wielding on us all, patients,
and practitioners.b) resist this abuse of EBM, c) to argue for more relevant
research questions, and c) to not simply bellow in rage.
Have you copied your 'rage' to them, asked for explanation of their
'language' steeped as it is in many years of well examined philosophical
discourse on the nature of knowledge and power, by many well intentioned
people? If not , why not?
Owen
Owen Dempsey
GP with special interest in education
Hon Sen Lecturer medical education, Leeds
Clinical Lead salaried GP scheme
Bradford City tPCT
Douglas Mill
Bowling Old Lane
Bradford
BD5 7JR
mobile 07760 164420
----- Original Message -----
From: "Poses, Roy" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, November 29, 2006 8:38 PM
Subject: post-modernists take another whack at EBH
A while back, I posted on Health Care Renewal
[http://hcrenewal.blogspot.com/] about post-modernist accusations that
proponents of EBM were "microfascists"
[http://hcrenewal.blogspot.com/2006/08/post-modernist-view-evidence-based.html/]
Here we go again. Thanks to a tip from the Capsules blog
[http://blog.meetingsnet.com/capsules/], I found this summary of a special
issue of Social Science Medicine on EBM
[http://annietv600.wordpress.com/2006/11/28/gift-horse-or-trojan-horse-the-ebm-debate-continues/].
In it was this article:
[http://dx.doi.org/10.1016/j.socscimed.2005.11.031]
Goldenberg MJ. On evidence and evidence-based medicine: Lessons from the
philosophy of science <http://dx.doi.org/10.1016/j.socscimed.2005.11.031> .
Social Science & Medicine 2006; 62(11):2621-2632.
This article has the now familiar attributes of post-modernist anti-EBM
diatribes:
Misconceptions of EBM
For example, the author never once acknowledged that EBM takes into account
clinical experience and the clinical context on one hand, and patients'
values on the other hand, in addition to the "evidence." That later allows
the author to accuse EBM of being an instrument of "the institutional power
of medicine" that is bad for women patients.
The author also equated EBM with logical positivism, "However, the apparent
obviousness of EBM can and should be challenged on the grounds of how
'evidence' has been problematised in the philosophy of science. In this
paper, I argue that evidence-based practices maintain an antiquated
understanding of evidence as "facts" about the world in the assumption that
scientific beliefs stand or fall in light of the evidence. This
understanding of evidence is explicitly positivist...." The author then
argued against logical positivism, and transferred all criticisms of it to
EBM.
Logical Fallacies
The author made particular use of false dichotomies. She argued that
logical positivism, and hence EBM, are based on the notion that people's
perceptions of external reality "are supposed to provide a a maximally
certain and conceptually unrevisable foundation of empirical knowledge,"
i.e., that perceptions of external reality are perfect. She then argues,
quite unremarkably, that perceptions of reality are imperfect, but then says
imperfect observations are essentially worthless. So the conclusion was
that logical positivist science, which again was equated with EBM, is based
on worthless observations, implying both such science and EBM are worthless.
The author made the usual post-modernist appeals to (post-modernist)
authorities. Since this was a feminist critique, the authorities in this
case were mostly feminists, although of course there was a bow to the
ubiquitous Foucault. In a particularly impenetrable section on "feminist
epistemologies of science," for example, she asserted
- "Notions of evidence and theories of epistemic agency are, therefore,
closely related. Haraway (1996)
<http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-4HWXP4C-1&_coverDate=06%2F30%2F2006&_alid=498309077&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5925&_sort=d&view=c&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=861b0a5ef32#bib29>
argues that the notion of 'matters of fact' depends on many kinds of
transparencies in the grand narratives of the experimental way of life. The
'modest witness', the protagonist of the dramas of the Scientific Revolution
who testifies without prejudice to new facts, had to be constructed in
sufficiently detached and abstracted terms to make plausible the unusual
situation where his experiences could somehow represent everyone's and
no-one-in-particular's experiences."
- "Lorraine Code has argued that 'objectivity' is 'a generalization from the
subjectivity of quite a small group' (1993, p. 22). However, this group 'has
the power, security, and prestige to...generalise its experiences and
normative ideals across the social order thus producing a group of like
minded practitioners ('we') and dismissing 'others' as deviant and aberrant
('they')' (Code 1993, p. 22
<http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-4HWXP4C-1&_coverDate=06%2F30%2F2006&_alid=498309077&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5925&_sort=d&view=c&_acct=C000039639&_version=1&_urlVersion=0&_userid=709070&md5=861b0a5ef32#bib8>
).
Setting aside, for a moment, the apparently deliberate obscurity of these
arguments, why should one believe them just because they were made by
Haraway or Code?
(Perhaps Deliberately) Turgid Writing
One wonders whether the editor of this article actually understood it all.
The writing is full of the clumsy constructions and opaque jargon usually
favored by post-modernists. I will save you further quotes. One wonders,
however, whether the purpose was to deliberately confuse the reader, in the
hopes that readers so confused would attribute their mental state to the
vast erudition of the author.
Finally, the Dire Warning
The author finally concluded that EBM is dangerous, at least to women, "
Feminist critiques of science are driven by a deep concern that the
abstractions made in the names of scientific objectivity, generalisability,
and predictability harm women. These tendencies appear to resurface in the
practice of EBM."
Furthermore, "Feminist insight reveals that the practices of EBM are marked
by potential or actual gender bias, which has led at least one critic to
argue that EBM is bad for women's health."
In Conclusion
[Borrowing some wording from my post on accusations of "microfascism," but
with specific quotes from the Goldenberg article referenced above... ]
Recovering from the brain fever induced by reading about "knowers" as
"collaborative agents," "experiential 'givenness,'" and "objectified
body-machines," one might speculate: 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?
If so, it's working.
Roy M. Poses MD
Clinical Associate Professor of Medicine
Brown University School of Medicine
email: [log in to unmask]
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