There is one source of evidence, 'the patient' who is rarely mentioned, except as case studies or anecdotes, which because they only involve a single case, are often regarded by health care professionals as the lowest level of evidence. This does not mean that what can be learned from individual patients is less important than what can be learned from a large study, only that these are different forms of evidence. The large study has more statistical power but it can really only confirm what was first seen in individual patients.

I believe this should be included in the Hippocratic Oath directly under "...do no harm" 

Listen to the patient

They are world authorities on their own illnesses and related symptoms. I calculated that some of the older patients at Blackfriars DDA Clinic have each had over 1000 hours of experience in clinical psychiatric practice. These patients can teach HCPs as much as any other resource. HCPs should keep detailed records of what patients say about their illness, even things that don't seem relevant or important can turn out to be crucial later. It is only the patient who can know [after discussions about treatments] whether or not the potential risks are worth the potential rewards.

Jo

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From: Anoop Balachandran <[log in to unmask]>
To: [log in to unmask]
Sent: Friday, 24 February 2012, 1:55
Subject: Re: Evidence Based Approach Question

Thanks everyone for the replies! I agree how the hierarchy is not an absolute measure of evidence.

 

I think the basic science part is sometimes ignored. I still see acupuncture and homeopathic trials though it is clear that there is no plausible mechanism AND it doesn't agree with our current scientific knowledge. The only rationale for conducting new studies are that the  prior RCT's trials were poorly designed.  Hence even the latest Cochrane  review demand more "well-designed RCT's" of Acupuncture for certain conditions.

 

So though basic science is emphasized even in the definition of EBM, it is not given adequate emphasis. Maybe we could have a grading system for basic science evidence too (or do we) :-)

On Thu, Feb 23, 2012 at 4:52 PM, jo kirkpatrick <[log in to unmask]> wrote:

Hi Paul

So do you think it would be safer to begin with the latest Meta-Analyses and/or Systematic Reviews we can find [assuming there are some] then look at some of the individual studies, and then back to SRs?

Best wishes Jo

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From: Paul Elias <[log in to unmask]>
To: [log in to unmask]; jo kirkpatrick <[log in to unmask]>
Sent: Monday, 20 February 2012, 4:01

Subject: Re: Evidence Based Approach Question

hi Jo, and I think that your approach is excellent...to me the issue is impacted by 1.) the go to source must be the systematic review or meta analysis and these must be the most current..most updated ones on the question 2.) if no reviews or meta analysis is done, then the best RCT paper/study and this too must be the most updated one based on the the search. 3. )to combine this approach with your learning in med school, experience, colleague discussions, past patient treatments and outcomes, and the patient values and preferences/their input in treatment decisions... but I think where we miss a step and fault is that we all assume that any evidence or science out there is the top and represents the most updated...which is what SRs aim to be and do..yet this is not the case and we have RCTs redone on same question in same way and give same results...same with some reviews...what we need is to build into the system the need to constantly be updating and evolving based on what is done...so that science really depends on a.) our ability to cogently share the knowledge we have gained via our research and b.) ensure that evidence or research study builds and adds...'ADDS'...this word is key..not regurgitate or redo...it must add or refine or summarize...there must be some value added and SRs really represents the gold standard as a means to summarize well conducted RCTs (quantitatively via meta analysis) as well as qualitative narrative type SRs...the aim is to bring together what has been done in one cogent statement...           Best, Paul E. Alexander   --- On Sun, 2/19/12, jo kirkpatrick <[log in to unmask]> wrote: From: jo kirkpatrick <[log in to unmask]> Subject: Re: Evidence Based Approach Question To: [log in to unmask] Received: Sunday, February 19, 2012, 10:35 PM Hi Anoop I think by basic sciences they probably mean basic medical, or biological sciences not basic general science but I am only a Graduate Student so I could be wrong. My take on EBM is that through the Internet we have access to the latest research findings, and we need to learn how to find suitable evidence and analyse its validity. We can't just accept research findings at face value then use them to justify medical decisions, especially after a less than thorough investigation of other possibly conflicting evidence. The idea is to use a balanced approach, and to consider all the available evidence carefully before using it to guide practice, e.g., informing patients and helping them to understand their illness and the available choices, particularly when you and the patient make treatment decisions. In the past patient were kept out of the decision-making discussions, and doctors relied on what they were taught as students combined with their professional experience. They took journals like the Lancet or BMJ to keep up with new research, but this wouldn't be enough now that there are hundreds of medical journals. When it comes to their health, today's patients are better educated and informed than ever before. They have Internet access and know about resources like Wikipedia, user driven self-help forums, and dedicated online communities, that connect them to other patients and people who are related to sufferers of the same condition. They can use forums to compare notes on new treatments and symptoms. Modern Health Care Professionals need to acknowledge the changes in what they expect patients to know by improving their own knowledge. EBM doesn't mean having a quick look online when we are stumped for answers; although even that is better than not looking online at all. There are many who will pay lip service to the paradigm, but to be effective in EBM, HCPs need to spend many hours in online libraries and searching databases to get up to date in their own area. Then several hours a week need to be devoted to keeping abreast of the latest research. Ideally these habits should be developed as students. My own M.O. is to search for one relevant article on a subject, then I use this to explore the referenced material to find other related articles. I repeat the process several times, each with narrower search criteria. Eventually this 'Cycle of Inquiry' provides a carefully chosen assortment of related research, which allows me to learn whatever I need to know. E.g. how and why different studies were done; what was learnt or concluded about potential causes, the efficacy of treatments, and long-term outcomes. This evidence can be used to support rather than justify decisions. I use meta-analyses for comparisons of overall effects, with individual findings; and systematic reviews to examine the overall consensus of findings from combined meta-analyses. If I only had time to read one article, I would probably choose one of these.  Best wishes Jo From: Anoop Balachandran <[log in to unmask]> To: [log in to unmask] Sent: Friday, 17 February 2012, 12:50 Subject: Evidence Based Approach Question I had a question about EBM. The definition of EBM is" The best available research evidence means evidence from valid and practically relevant research , often from the basic sciences ..." So can we use just basic science to justify a treatment? Can anyone give an example please. Thanks.