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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 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 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 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 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
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:
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]" rel="nofollow" target="_blank">[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