Joe Mathews said
Clearly the problem lies in the popular conception of evidence-based
health care as a quantitative discipline. This is not only misleading,
but demonstrably incorrect. The late great programme in EBHC, offered
through the University of Oxford department of continuing education,
was not only appreciative of qualitative research methodologies, it was
directed by a qualitative researcher, Dr. Janet Harris. Students in
this programme received training in quantitative and qualitative
methodologies with an elective module in advanced QRM during the MSc
year. Our struggle against this misunderstanding-of-what-EBM-is-all-about
should point out that diverse questions require diverse research
methodologies to develop best evidence. Appropriate rigour is required
in all of these. Recognizing high quality research and becoming good
consumers and generators of evidence was the forte of the three year
EBHC degree curriculum at Oxford; alas, sadly, no more.
I don't think the problem is that they don't understand that EBM can use qualitative as well as quantitative data.
We have to admit EBM has a rather fanciful and pseudo scientific 'Hierarchy of evidence' .
Where does qualitative research stand in the hierarchy. Can there be a 'true RCT' with qualitative data? If not, then we have devalued qualitative data from the point go.
EBM was devised to get to the unbiased truth - away from the promotions of vested interests.
Unfortunately vested interests have mastered the art of using EBM to their advantage.
RCTs cost money.
So most of the RCTs are done by drug companies.
The Vioxx story is too recent to bear repeating.
Merck used the 'Hierarchy of Evidence' and their RCTs to deny epidemiological evidence of harm for a very long time.
The story with Surfactant published by the BMJ is another case in point.
(Truth and evidence based medicine: spin is everything.Tiwari L, Puliyel JM, Upadhyay P.
BMJ. 2004 Oct 30;329(7473):1043)
Most of the the Cochrane reviews on Surfactant have been authored by one author whose conflict of interest declaration makes it clear he has been paid by nearly every surfactant manufacturer. Yet, in spite of repeatedly writing, no change has been made to this review.
EBM has made life easier for those who want to manipulate the evidence. The question is 'How may we redeem the situation?'
Jacob Puliyel MD MRCP M Phil
St Stephens Hospital, Delhi, India.
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On 3/23/07, brnbaum <
[log in to unmask]> wrote:
Peter Renshaw posted:
> Yet another paper that assumes that evidence-based practice is all
> about statistics and completely ignores that the well-described role
> of clinical experience in the application of evidence-based medicine
> (not to mention patient preferences).
>
> Have we failed to highlight clinical experience enough?
IMHO, what is needed to better frame evidence-based practice isn't more emphasis on experience per se, but choice of a better theoretical framework. As an attractive alternative to "tacit knowing" one might look at the fourth knowledge dimension presented by Anderson, Krathwohl, et al. (A Taxonomy for Learning, Teaching and Assessing: A Revision of Bloom's Taxonomy of Educational Objectives, 2001, Addison Wesley Longman Inc.). Their taxonomy presents 6 cognitive dimensions on one axis, 4 knowledge dimensions on a second.
Their 4 knowledge dimensions are factual knowledge, conceptual knowledge, procedural knowledge, and metacognitive knowledge. One could present EBM as being as sure as possible the conceptual knowledge (principles, theories, classifications, etc.) correctly explains interrelationships of factual elements and those facts are identified without significant bias (as by critical appraisal of biomedical literature), while also appreciating context & strategy (the cognition and awareness related to experience in practice). One element of their procedural knowledge is "knowledge of criteria for determining when to use appropriate procedures" which also could reflect EBM's concern about employing procedures most likely to produce an intended outcome.
That approach would permit us to hang both quantitative & qualitative values within the matrix. Thus, it might be a better fitting framework for the comprehensive picture.
David.
--
David Birnbaum, PhD, MPH
Adjunct Professor
School of Nursing
University of British Columbia
Principal, Applied Epidemiology
British Columbia, Canada
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___________________________
Jacob M. Puliyel MD MRCP MPhil
Sara Varughese DO FRCS MSc(LSHTM)
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Phone 00 91 11 2946388
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