Thank you, Ash - I am not debating this point at all. Working in the NHS, I
fully appreciate the need to allocate finite healthcare resources in the
most efficient and cost-effective way, based on the best available
evidence. From this point of view, I would argue that funding a major
improvement in a tertiary healthcare facility is a much better use of public
money than providing (say) enzyme replacement therapy to a child with a rare
metabolic disorder. However, when the parents of the said child are sitting
in front of you, you (as a clinician) are expected to be the advocate of
their (child's) interests. And then it becomes a real ethical issue with no
clear answer that would prove satisfactory to all parties.
I completely agree that some clinicians indeed do not have a good working
knowledge and understanding of EBM; and that it is our responsibility to
gain understanding of the subject with the aim of applying it in our
practice, communicating relative advantages&disadvantages of various
treatment options to our patients (for example). However, good
understanding of clinical epidemiology and healthcare economics does not
eliminate the ethical obligations of the doctor-patient relationship and the
philosophical dilemma of personal vs public interests.
best wishes,
Liliya
2009/2/1 Ash Paul <[log in to unmask]>
> Dear Liliya,
> Many thanks for this.
> Can I just refer you to the competencies of the Royal College of Physicians
> and Surgeons of Canada, which all medical trainees need to acquire in their
> entirety before they become consultant physicians or surgeons in Canada:
> http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf
> If you look at page 6 of the pdf copy, these are the following competencies
> that they have to have acquired:
> *3. Allocate finite healthcare resources appropriately *
> **3.1. Recognize the importance of just allocation of healthcare
> resources, balancing effectiveness, efficiency and access with optimal
> patient care
> 3.2. Apply evidence and management processes for cost-appropriate care
> My argument as a healthcare commissioner is that the practice of EBM cannot
> be looked upon in isolation by physicians and surgeons working in finitely
> publicly funded healthcare systems.
> Regards,
> Ash
>
>
>
> --- On *Sun, 1/2/09, Liliya Bakiyeva <[log in to unmask]>* wrote:
>
> From: Liliya Bakiyeva <[log in to unmask]>
> Subject: Re: Mammography Screening Info from BMJonline
> To: [log in to unmask]
> Date: Sunday, 1 February, 2009, 6:14 PM
>
>
> I guess, this extract from The Economist could add some perspective...
>
> "Human life is priceless. But this has not stopped economists trying to put
> a financial value on it. One reason is to help FIRMS<http://www.economist.com/research/Economics/alphabetic.cfm?term=firms#firms>and policymakers to make better decisions on how much to spend on costly
> safety measures designed to reduce the loss of life. Another is to help
> insurers and courts judge how much compensation to pay in the event of, say,
> a fatal accident. One way to value a life is to calculate a person's HUMAN
> CAPITAL<http://www.economist.com/research/Economics/alphabetic.cfm?term=humancapital#humancapital>by working out how much he or she would earn were they to survive to a ripe
> old age. This could result in very different sums being paid to victims of
> the same accident. After an air crash, probably more MONEY<http://www.economist.com/research/Economics/alphabetic.cfm?term=money#money>would go to the family of a first-class passenger than to that of someone
> flying economy. This may not seem fair. Nor would using this method to
> decide what to spend on safety measures, as it would mean much higher
> expenditure on avoiding the death of, say, an investment banker than on
> saving the life of a teacher or coal miner. It would also imply spending
> more on safety measures for young people and being positively reckless with
> the lives of retired people.
> Another approach is to analyse the risks that people are voluntarily
> willing to take, and how much they require to be paid for taking them.
> Taking into account differences in WAGES<http://www.economist.com/research/Economics/alphabetic.cfm?term=wages#wages>for high death-risk and low death-risk jobs, and allowing for differences in
> education, experience, and so on, it is possible to calculate roughly what
> value people put on their own lives. In industrialised countries, most
> studies using this method come up with a value of $5m–10m."
> At the end of the day, though, as Ben said, regardless of the value the
> economists may put on an abstract human life, for every one of us life is
> the most precious asset. Every patient will think about their own
> interests, above anything else (and why should not they?) And as for
> clinicians, does our duty to the society outweigh our duty to THE patient
> that is sitting in front of right now? These are difficult questions...
>
> PS The link to the website is here
>
> http://www.economist.com/research/Economics/searchActionTerms.cfm?query=policymaker
> 2009/2/1 Djulbegovic, Benjamin <[log in to unmask]>
>
>>
>> *Ash, thanks*
>> *I think the article states that the "*value of a YEAR of quality human
>> life is about $129,000" (not the value of human life). Regardless, whether
>> it is $1.54, $6 millions, or $600 millions it is the value-driven estimate,
>> which will always defy the universal consensus. BTW, I am not disagreeing
>> with what you said, I am only try to explain why we are seeing the types of
>> decisions you've described.
>> Best
>> ben**
>>
>> *From:* Evidence based health (EBH) [mailto:
>> [log in to unmask]] *On Behalf Of *Ash Paul
>> *Sent:* Sunday, February 01, 2009 12:50 PM
>>
>> *To:* [log in to unmask]
>> *Subject:* Re: Mammography Screening Info from BMJonline
>>
>> Dear Benjamin,
>> According to recent research published by Stanford University Graduate
>> School of Business, the value of human of life in the USA is nowhere
>> nearly as costly as 6 million dollars. Infact, according to Stefanos Zeinios
>> and his colleagues at Stanford, the value of human life is more likely
>> just $129000, using renal dialysis as a benchmark.
>> I don't have the article at hand but this was the subject of a Time
>> Magazine article in May 2008:
>> http://www.time.com/time/health/article/0,8599,1808049,00.html
>> If the value of human life is so little, you can now see why public
>> health commissioners of finitely funded healthcare systems in the Western
>> world are constantly coming into conflict with bedside clinicians who use
>> EBM as the magic wand to justify all their bedside clinical decisions on
>> individual patients. Funding a named patient A always means that an unnamed
>> Patient B or a group of unnamed patients will have to forego treatment via
>> opportunity cost. But just because nobody hears or sees them, should they be
>> ignored? Surely clinicans have a moral duty to society as well as to their
>> individual patients?
>> Way back in 2002, however, Orley Ashenfelter of Princeton University and
>> Michael Greenstone of Chicago University calculated the value of human life
>> at 1.54 million dollars in the USA, within the context of setting public
>> policy about highway safety.
>> Regards,
>> Ash
>>
>>
>>
>>
>> --- On *Sun, 1/2/09, Djulbegovic, Benjamin <[log in to unmask]>*wrote:
>>
>> From: Djulbegovic, Benjamin <[log in to unmask]>
>> Subject: Re: Mammography Screening Info from BMJonline
>> To: [log in to unmask]
>> Date: Sunday, 1 February, 2009, 5:01 PM
>>
>> *The problem, of course, is that the end of the day, and when everything
>> is said and done, we are left with "the problem of single case"-uncertainty
>> about applying of trial ("group averages") data to bedside. In case of Ash's
>> renal cancer patient the crucial word here is "probable" i.e. that the
>> patient will most PROBABLY die within 3 months despite of taking £40000
>> worth of new anti cancer medication? But, in the patient's case it is always
>> 0 or 1, i.e. ** the knowledge of class probability cannot tell us
>> anything about a particular case at hand, which is the reason that we
>> continue to see that decisions are being made by majority of practitioners (
>> myself included, doing it on almost daily basis). When this discussion is
>> further extended, it inevitably leads to the most uncomfortable questions of
>> all: what is price of hope, uncertainty, or life for that matter? (many
>> economists model the price of life at $6 millions).*
>> *EBM cannot help here- ultimately it is going to require broader societal
>> consensus related to group vs. individual interests. What EBM bets on is
>> that these decisions may become more palatable if we finally acknowledge
>> that one of the key problems in medical practice and chief source of
>> uncertainty is the lack of reliable information and poor quality
>> evidence that inform most our medical decisions. In many cases, what we used
>> to believe is a small probability of BENEFIT turned out to be not so small
>> probability for HARMS.*
>> *ben*
>>
> * *
> * *
>
> *Benjamin Djulbegovic, MD, PhD*
> *Professor of Medicine and Oncology*
> *Co-Director of Clinical Translation Science Institute*
> *Director of Center for Evidence-based Medicine and Health Outcomes
> Research*
> * *
> *From:* Evidence based health (EBH) [mailto:
> [log in to unmask]] *On Behalf Of *Paul Alexander
> *Sent:* Sunday, February 01, 2009 9:02 AM
> *To:* [log in to unmask]
> *Subject:* Re: Mammography Screening Info from BMJonline
>
> Good day, this string is excellent and raises again the important issue
> of applying EBM to decision making in the increasing era of budget cutbacks
> and tightening. The issue is that to make the best cost effective decisions,
> we need the good sound evidence to back it up and share this with the
> patient in a patient focused manner. This is a very challenging area for
> there are the ethics of decison making and funding one at the cost of the
> other...I agree with Dr Paul Ash that the issue is a lack of these issues
> being dealt with in the medical schools. Clinical epidemiology, EBM, cost
> effectiveness etc. must be focused on. Explaining the risks and benefits to
> the patient can go a long way.
>
> I support the EBM approach and think that well applied, can be very
> useful and important in an era of cutbacks and funding challenges. For the
> most cost effective decision, options.
>
>
>
>
>
>
> Best,
>
> Paul
>
>
> --- On *Sun, 2/1/09, Ash Paul <[log in to unmask]>* wrote:
>
> From: Ash Paul <[log in to unmask]>
> Subject: Re: Mammography Screening Info from BMJonline
> To: [log in to unmask]
> Date: Sunday, February 1, 2009, 4:38 AM
>
> Dear Douglas,
> 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.
> Regards,
> *Ash*
>
> Dr Ash Paul
> Medical Director
> NHS Bedfordshire
> Gilbert Hitchcock House
> 21 Kimbolton Road
> Bedford
> MK40 2AW
>
> ( 01234 795705
> 4 01234 745896
> * *[log in to unmask]*<http:[log in to unmask]>
>
>
>
>
>
> --- On *Fri, 30/1/09, Marcus Tolentino Silva <[log in to unmask]>*wrote:
>
> 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: venerd́ 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
>
>
> ------------------------------
>
>
>
>
> --
> Liliya
>
> "The test of a first-rate intelligence is the ability to hold two opposed
> ideas in mind at the same time and still retain the ability to function." -
> F. Scott Fitzgerald
>
>
--
Liliya
"The test of a first-rate intelligence is the ability to hold two opposed
ideas in mind at the same time and still retain the ability to function." -
F. Scott Fitzgerald
