“An *expert* is a man who has made all the mistakes which can be made, in a
narrow field.” - Niels Bohr
I once said to my students "clinical guidelines are for dummies"... ie, if
I am a rookie inexperienced physician in a rural area, taking care of a 2
month old baby with fever, I will go with the guidelines and I am pretty
sure I will do more good than harm following a good guideline than not
following it. On the other hand, if I am an experienced paediatrician I will
rarely see the guideline on EVERY patient with fever I see, perhaps only
when it is recently published and to see what is new and what the course of
action "should" be, as I know it is based on the best evidence available.
Difficult thing is how to make physicians (novice and experts alike) to be
up-to-date with clinical guidelines for every condition?
I quote an article by Pantell et al:
*Pediatric clinicians in the United States use individualized clinical
judgment
in treating febrile infants. In this study, relying on current clinical
guidelines would
not have improved care but would have resulted in more hospitalizations and
laboratory
testing.
JAMA. 2004;291:1203-1212*
Would this be true in other areas?
If I am on a rural area (whatever the reason) and it happens that I have to
attend an acute myocardial infarction in a 60 y.o. man, I better follow a
clinical guideline, as I am not an expert on that field any more.
I like Ben´s idea about expertes in EBM (evidologists?)
On Wed, Sep 2, 2009 at 12:15 PM, Djulbegovic, Benjamin <
[log in to unmask]> wrote:
> thanks, Felice
> it appears from your and other response that it is content (and context)
> that matters. This is probably a reason why people do not consult guidelines
> outside their fields. This is certainly true for me: I rarely consult
> guidelines outside of my field, while I do consult hem-onc guidelines often
> (even those that I helped develop!) particulary when I want to deviate from
> the guideline. Time is a key factor, since I am so familiar with guidelines
> in my own field and I can find what I am looking for within 1-2 minutes,
> while it would probably take me 20-30 minutes to understand/consult the
> guideline outside of my own specialty. I should also mention that (outside
> giving cancer-specific treatments and some other treatments that are outside
> of purview of generalists, e.g. treating hemophilia...) >90% cases in which
> I am asked to give second opinion/consult relate to providing
> information/evidence to the questions requested in the referrals. Since all
> available information to me are equally accessible to anyone else ("there is
> no secret knowledge in medicine"- I often tell to the referring docs and
> patients alike), in theory docs could just dial EBM services and get the
> answers to the questions asked? But such services will be devoided of the
> context/content. So, ultimately content will always win...I think what EBM
> movement ought to do is to re-focus effort from generalists and consumers to
> train suspecialists ("experts") in EBM methods...
> ben
>
> ________________________________________
> From: Evidence based health (EBH) [[log in to unmask]]
> On Behalf Of [log in to unmask] [[log in to unmask]]
> Sent: Wednesday, September 02, 2009 6:01 AM
> To: [log in to unmask]
> Subject: Re: EBM and increasing requests for the use of consultants...
>
> Hi Ben and Others,
> Very interesting discussion here.
> I think that evidence based guidelines are not easy to develop and use.
> That's why Ebguidelines production is not in CME and educational programs
> for health care workers. EBguidelines need to be continuously updated and
> adapted. More over there is no interest in health care managers and
> directors to use Ebguidelines adopted in real practice as evaluation
> criteria for physicians, consultants, referrals and so on. Is there no trust
> about Ebguidelines use is correlated to better outcomes for patients?. There
> is no clear policy about this.
> So i do not think EBM rising (as EBguidelines use in real practice) can
> justify requests of the use of "experts" . It is true the contrary.
>
> Felice Musicco
> Hospital Pharmacist in Rome, Italy
> www.ifo.it
> ---------- Initial Header -----------
>
> From : "Evidence based health (EBH)"
> [log in to unmask]
> To : [log in to unmask]
> Cc :
> Date : Wed, 2 Sep 2009 08:09:21 +0530
> Subject : Re: EBM and increasing requests for the use of consultants...
>
>
>
>
>
>
>
> > Forwarding this message from Scot who is unable to register for this list
> > but is responding to the discussion:
> >
> > Rakesh, I probably cannot post to the EVIDENCE-BASED-HEALTH group, so
> please
> > pass this along:
> >
> > *The need for information is often much more than a question about
> medical
> > knowledge. Doctors are looking for guidance, psychological support,
> > affirmation, commiseration, sympathy, judgment, and feedback. This
> > "information need" is particularly poorly explored
> > *
> >
> > I strongly agree with the above passage, find it quite novel and apropos,
> > but foresee even greater difficulties "selling" this information need to
> the
> > IT and finance personnel who generally control information tools in the
> > enterprise. For example, at the link below is what occurred at one of
> the
> > largest pharma research labs in the world, where selling the idea that
> drug
> > discovery scientists needed the best informatics tools fell flat. Not
> > intuitive, but that's the way it was.
> >
> > See:
> >
> > "Sure path to R&D failure: Conflation of IT with information science in
> the
> > pharmaceutical industry"
> >
> http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=pharma
> >
> > Scot
> >
> > --------------------------------
> > Scot M. Silverstein, MD
> > Consultant in Medical Informatics
> > Teaching faculty in Healthcare Informatics and IT (Sept. 2007-)
> > Director, Institute for Healthcare Informatics (2005-7)
> > College of Information Science and Technology
> > Drexel University
> > 3141 Chestnut St.
> > Philadelphia, PA 19104-2875
> >
> > Email: [log in to unmask]
> > Bio: www.ischool.drexel.edu/faculty/ssilverstein/biography.htm
> > Common Examples of HIT difficulty:
> > www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm
> > ARS KU3E, member www.arrl.org
> > ________________________________________
> >
>
--
Carlos A. Cuello-García, MD
Director, Centre for Evidence-Based Practice-Tecnologico de Monterrey
Cochrane-ITESM coordinator. Professor of Paediatrics and Clinical Research
Avda. Morones Prieto 3000 pte. Col. Doctores. CITES 3er. piso,Monterrey NL,
México. CP64710
Phone. +52(81)88882154 & 2141. Fax: +52(81)88882019
www.cmbe.net
http://twitter.com/CharlieNeck
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