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I think perhaps what is being said is that when values are inadvertently ignored and needs for basic care are not met compliance is low and evidence is lost to attrition. In every discipline there is human error and not all decisions are logic based. 'Instinctive' fast type one decisions are needed in response to fight /flight scenarios and may be aided by good procedural knowledge, pattern recognition and cognitive control but they are applied too when people are tired, over confident, or stressed and tragically when a type 2 decision requiring knowledge, logic, reason and considering choices for multiple outcomes is needed. Perhaps when values or personal validity are threatened it provokes a knee jerk type one decision when the situation would be better managed with a type 2 decision platform, likewise if an angry bear is coming towards you that is not a good time to consider it's diet and personal life in detail. So the challenge as I see it is not that human error takes place but rather once it occurs how can this problem be solved and relationship be salvaged. I am a little puzzled as to the logical fallacy here: as to why someone who says if it were not for the mammography that detected a tumour deep inside I could not feel and may have grown to stage 3 before I noticed , I could have lost my life. I am grateful for the technology because it likely saved my life... The person is not saying all people have tumours deep inside cause I did and therefore they all need mammography they are only saying that it worked for them to facilitate an important diagnosis. If a lot of people around you get these tumours though it would seem to make sense to ask for screening???? If you are saying the poster commits a logical fallacy because she has based her medical decisions on events rather than peer reviewed evidence it would seem that she has considered the peer reviewed evidence as it was applied to her by others a logical fallacy in that its operation allowed adverse events and because she initially trusted medicine as a voice of authority and was betrayed she turned the volume down...to her it is logical. One way this could be overcome is by listening with a mind to hear without preconceived filters so that the difference between knowing that and knowing how can be bridged and the very real conflict can be resolved. And when you say you have personal examples of no adverse deregistering events happening due to mammography refusal and you say that you have non- medical friend examples too...does this mean it could not possibly happen to someone else ? Is this evidence based or is this a logical fallacy, please explain as this has my head spinning... are you saying that patient examples are logical fallacy but authority based physicians examples are not and that the physician's friends in this example are exempt from logical fallacy inclusion because they are covered by the relationship to the physician? Many thanks Amy From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of k.hopayian Sent: 27 November 2011 05:24 AM To: [log in to unmask] Subject: Re: New breast cancer screening guidelines released Canada_underscoring the need for decision making based on evidence Hi Jo, With due respect for your painful experience, I have to say that I do not see anything in your mail that relates to evidence-based health. You report that on two occasions, doctors failed to make the correct diagnosis. That is not a logical argument for writing off mammography. It is as illogical as the argument from people who say, I owe my life to mammography because it found a cancer before I could feel it. Let me see if I can classify reasons for a missed diagnosis: 1. The medical knowledge is there, but the doctor is ignorant. 2. The medical knowledge is there and the doctor is aware of it but misapplies the knowledge. This could lead to a another discussion on the classification of human error (your cue, Neil Maskrey?). 3. The medical knowledge is there and the doctor is aware of it and applies the knowledge correctly but a false negative has occurred. It happens. In EBHC, we are trying to understand how to use our knowledge of test accuracy to improve care. This applies to choosing the best tests and being aware of their limitations. 4. The medical knowledge itself is mistaken. 5. The medical knowledge is not there yet. I must point out to our members outside the UK that your case of being removed from a general practice register simply for declining screening, as alleged, is atypical of the UK. Whether one has mammography or not, one can expect general medical care to continue. I have many examples from my own practice and from my (non-medical) friends. Kev On 27 Nov 2011, at 01:50, jo kirkpatrick wrote: Yes I am afraid I am one of the Non-responders to invitations for mammograms. As tumours can be outside the actual breast I find the mammogram less than reassuring so I ignore the invitations and check myself. I also feel having recovered from at least two potentially fatal conditions, with no help at all from medical science [not even a correct diagnosis until it was over] I am not prepared to play any more or let 'them' play with me. I refuse to entertain the possibility of another serious illness, it is the only way I can function. Of course anyone thinking of following suit should be warned that in the UK you might find your GP's Area Health Authority has had you removed from his list without so much as a phone call to you. When you try to make an appointment you have to reregister first, after 40 years with the practise. Best wishes Jo _____ From: k.hopayian <[log in to unmask]> To: [log in to unmask] Sent: Saturday, 26 November 2011, 20:24 Subject: Re: New breast cancer screening guidelines released Canada_underscoring the need for decision making based on evidence Hi Ben, Not sure that I agree that this is just a question of attitudes to risk. While I accept that there is individual variation in attitudes to risk (meaning bad things) and risk (meaning the chances of those bad things happening), there is also a social dimension. That social dimension includes, amongst other things, the message broadcast by those perceived to be authorities, in this case, guideline developers and disseminators. And in many countries, guideline developers have recommended the provision of mammography screening based on their interpretation of the evidence as showing that screening reduces mortality. The disseminators have urged women to follow these guidelines. It is in this social environment that women must make decisions. Women who do not respond to invitations for screening will be seen as deviating from official policy and their peers who mostly do attend. Their computer record will flash up Non-Responder whenever they consult the general practitioner. Now if the guideline developers take the view that mammography is not effective in reducing mortality (which the Canadian Task Force appears to do) and go further and do not recommend it be provided (which the Task Force stopped short of doing), then the environment will be a very different one. Therefore, a further look at the evidence and further debate may well influence future recommendations. BTW, it is interesting to observe that the Can Task Force did not take that extra, terrifying step, of recommending that screening mammography be withdrawn. Social forces at work again?!? Dr Kev (Kevork) Hopayian, MD FRCGP General Practitioner, Leiston, Suffolk Hon Sen Lecturer, Norwich Medical School, University of East Anglia GP CPD Director, Suffolk [log in to unmask] http://www.angliangp.org.uk/ Making your practice evidence-based http://www.rcgp.org.uk/bookshop On 25 Nov 2011, at 19:20, Djulbegovic, Benjamin wrote: I think no further look at evidence will resolve the screening mammography question. This is a question of VALUES and how we weigh false positives (unnecessary biopsies, surgeries etc- regret of commission, of unnecessary) vs. false-negatives (missing cancer, delay in diagnosis, etc- regret of omission, of potentially failing to save lives). Because our risk attitudes inherently differ (there is no such a thing as "right" or "wrong" risk attitude), no guidelines panels can make recommendation for a woman facing decision whether to accept invitation to screening mammography. This is best summarized by Lesley Fallowfield in one of the papers to which Ash provided links provided below, and Fiona Godlee in her editorial when she says that she "speaks for many women when she admits that, despite her own detailed knowledge of the science, she is uncertain of the value of mammography screening. "I feel silly for attending screening, but scared not to do so." Ben Djulbegovic From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Ash Paul Sent: Friday, November 25, 2011 1:47 AM To: [log in to unmask] Subject: Re: New breast cancer screening guidelines released Canada_underscoring the need for decision making based on evidence Dear Paul, In this week's excellent issue of the BMJ, we have some very good articles on the subject of breast screening. Two of them are by members of this Group, Fiona Godlee and Klim McPherson: <http://bmj.com/lookup/doi/10.1136/bmj.d7623?etoc> Mammography wars Fiona Godlee <http://bmj.com/lookup/doi/10.1136/bmj.d7625?etoc> Women in their 40s should not be screened for breast cancer, new Canadian guideline says Adrian O'Dowd <http://bmj.com/lookup/doi/10.1136/bmj.d7529?etoc> Breast cancer screening review: We need scientific consensus founded on all the evidence Klim McPherson <http://bmj.com/lookup/doi/10.1136/bmj.d7535?etoc> Breast cancer screening review: An appeal to Mike Richards Michael Baum <http://bmj.com/lookup/doi/10.1136/bmj.d7544?etoc> Breast cancer screening review: What should women do in the meantime? Lesley J Fallowfield Regards, Ash From: Paul Elias <[log in to unmask]> To: [log in to unmask] Sent: Thursday, 24 November 2011, 17:14 Subject: New breast cancer screening guidelines released Canada_underscoring the need for decision making based on evidence http://www.eurekalert.org/pub_releases/2011-11/cmaj-nbc111611.php Best, Paul E. Alexander