You moderate an outstandingly excellent e-group (and one that I'm proud to be a member of, albeit mostly a silent member) but I agree with Neal, Marcus and Frederico, speaking with my NHS PCT commissioners hat on, we do need to discuss these sensitive topics openly and boldly in excellent internationally respected e-groups groups like this.
Neil is absolutely right, most busy clinicians, the lay public and the politicians have no concept about relative and absolute risk and more worringly, many of the clinical leaders have no understanding of epidemiology, population medicine and cost effectiveness. It is also a relatively neglected topic in the medical school curriculum. What we need to consider in the UK is how can we apply evidence-based medicine effectively in order to improve the health of the population and reduce health inequalities within the NHS. All of us clinicians should feel ashamed that in 29 years since the Black Report was first published in 1980, health inequalities in Britain have gone up by a further 2 years inspite of the many extra billions spent on the NHS. To spend £40000 of NHS money on a new cancer drug for a single patient with a fourth relapse of multiple myeloma is in my mind, not a good
use of the practice of evidenced-based medicine, because it deprives me as an NHS commissioner from investing £40000 pounds in palliative care for the entire community. As clinicians, we must learn not to peddle immortality to patients on the back of evidence-based medicine. We must also consider how we can use evidence-based medicine to prepare proper information aids for patients. Why should I as the PCT's Medical Director have to tell the renal cancer patient that s/he will most probably die within 3 months inspite of taking £40000 worth of new anti cancer medication? Surely that is the duty of the clinician who prescribes the medicine using his or her knowledge of evidence-based medicine to properly explain the risks and benefits of the drug to his/her patient?
Academicians and researchers on the other hand, have no practical idea how difficult it is for NHS PCT public health commissioners to convince clinicians about the practical applications of evidence-based medicine and its use in commissioning in a finitely funded healthcare system. They have no idea of opportunity costs and the ethics of commissioning. In a finitely funded healthcare system, the medical ethics of autonomy which explores individual doctor patient relationships, needs to give way to the public health ethics of interdependence ie the realisation that funding one patient on the back of dubious and badly interpreted evidence actually affects the health and welllbeing of the entire community through opportunity cost.
The days of EBM surviving and flourishing within an academic silo have long gone, and if they haven't, they soon will, with the present global financial crisis affecting publicly funded healthcare systems next on its hit list. If you speak to Sir Muir Gray, Chief Knowledge Officer of the NHS and Professor at Oxford and the guru of EBM, and who I'm sure you know very well already, I'm absolutely convinced that he will confirm everything that Neal, Marcus and Frederico have written here. In fact, I'm willing to stake my life on that and I'm copying Sir Muir into this email as well.
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From: Marcus Tolentino Silva <[log in to unmask]> Subject: RES: R: ENC: [Consumers] Mammography Screening Info from BMJonline To: [log in to unmask] Date: Friday, 30 January, 2009, 8:10 PM
Apparently, researchers that work with EBM and HTA like to speak of his finds for others researchers that works with EBM and HTA. It looks me that this vicious circle does with that the dissemination examples of the knowledge in EBM and HTA prompt the natural resistance by some researchers. -----Mensagem original----- De: Evidence based health (EBH) [mailto:[log in to unmask]] Em nome de Maskrey Neal Enviada em: sexta-feira, 30 de janeiro de 2009 13:30 Para: [log in to unmask] Assunto: Re: R: ENC: [Consumers] Mammography Screening Info from BMJonline Bravo,
Frederico! If the EBM movement focuses on processes and methodological issues only (important though those are) and fails to address the issues of fair accurate and balanced translation of the best available evidence in ways that patients, the public and busy clinicians can readily understand, then we are in trouble. Mammography screening is an excellent example of the issues. Most clinicans and almost all patients can't get to grips with
relative and absolute risk despite 20 years of industrial strength, traditional EBM teaching and writing. We need to find ways of helping them that are innovative, because the current approaches are not working. Bw Neal Neal Maskrey National Prescribing Centre Liverpool UK -----Original Message----- From: Evidence based health (EBH) <[log in to unmask]> To: [log in to unmask] <[log in to unmask]> Sent: Fri Jan 30 12:21:45 2009 Subject: R: ENC: [Consumers] Mammography Screening Info from BMJonline [forgive my English] I don't agree, Douglas. Debate about mammography screening is at present one of the most important methodologic arena for Evidence Base Health. We need to talk extensively about it. Kind regards. dott. Federico Barbani Servizio Committenza (health purchasing service) Azienda USL di Modena via San Giovanni del Cantone 23 41100 MODENA, Italy tel 059/435813 - 435731 -----Messaggio originale----- Da: Evidence based health (EBH) [mailto:[log in to unmask]] Per conto di Douglas
Badenoch Inviato: venerdì 30 gennaio 2009 13.08 A: [log in to unmask] Oggetto: Re: ENC: [Consumers] Mammography Screening Info from BMJonline Just a quick reminder to list members, please don't post attachments to the list. Instead you should either post a link to the document, or offer to email it to people who are interested. Secondly, I think that this message would be better on a topic-specific list, such as one dedicated to women's health, rather than on EBH, which is about issues relating to the process of EBH. I guess there may be generic, process-type questions which may arise from this, such as how to achieve truly evidence-informed
patient choice, but I would look to the original author to state what that question is. Thanks Douglas [log in to unmask] Marcus Tolentino Silva wrote: > > > ---------------------------------------------------------------------- > -- > *De:* Maryann Napoli [mailto:[log in to unmask]] *Enviada em:* > quinta-feira, 29 de janeiro de 2009 14:43 > *Para:* [log in to unmask] > *Assunto:* [Consumers] Mammography Screening Info from BMJonline >
> Mammography stands out from all other cancer screening tests with the > quantity and quality of its research support. Yet the documented > harms associated with this procedure are withheld from women (no > matter where they live). This is the message of the attached article > from BMJ online with authors from the Nordic Cochrane Centre and > University of Copenhagen. The other attachment (from same authors) > is, in my opinion, the first honest pamphlet aimed at women who want > to make an informed decision whether or not to undergo mammography > screening. > > > > Best wishes, > > > > Maryann Napoli > Center for Medical
Consumers > 239 Thompson St. > New York, New York 10012 > 1(212) 674-7105 > www.medicalconsumers.org <http://www.medicalconsumers.org> > [log in to unmask] <mailto:[log in to unmask]> > > . > -- Mr Douglas Badenoch Director, Minervation Ltd ------------------------- 23 Bonaly Grove Edinburgh EH13 0QB ------------------------- Tel: +44 131 441 4699 Web: www.minervation.com ------------------------- Minervation is a limited company registered in England and Wales Registered number: 4135916 VAT number: 792674384 Registered Office: Salter's Boat Yard, Folly Bridge, Abingdon Road, Oxford, OX1 4LB |