What a fascinating editorial by TG! My apologies if I am repeating what others have said, but I have been out of circulation for a while and may have missed
earlier comments.
To my view, she has eruditely put into words what many of us have been trying to say for some time – that the EBM paradigm must be seen in a broader context. I see no suggestion in the editorial that we should abandon the principles of EBM at all. What we need to do is ensure that EBM stays the clinical tool it was originally conceived to be – that is to say, a tool for us clinicians to assist patients (see the
editorial for some other useful tools that should be integrated). TG is pointing out that allowing it to be misconstrued/misused by non-clinicians as a means to limit the provision of thoughtful care to patients is a situation for which many of us may (partly
and perhaps unwittingly) be to blame.
I do NOT take it as a rejection of EBM, but as a timely warning not to let EBM become a religion. My own local and much less erudite exhortation to colleagues
has been that they had better become familiar with the language and practice of EBM because, not only does it assist good practice, but sooner or later bean-counters and managers are going to try and bamboozle us by misusing EBM tools in order to control our
behaviour. We need to recognise and resist their efforts – and understanding the language is essential for that.
Mike Bennett
Sydney
From: Evidence based health (EBH) [mailto:[log in to unmask]]
On Behalf Of Amy Price
Sent: Tuesday, 3 July 2012 7:19
To: [log in to unmask]
Subject: Re: journal of primary health care and article on probabilitistic reasoning
Dear Bruce and All,
I like your probalistic paper and they way you have tied the nomogram to useful outcomes.
I am beyond confused by the Trish Greenhalgh paper as I am presently enrolled in the EBHC course at Oxford and have taken 6/6 modules. There is not one module where Dr. Greenhalgh's present
concept of EBM was taught or encouraged, quite to the contrary. In every module we are asked to consider type 1 and 2 decision making and how clinical decisions, guidelines, how we write reviews or design experiments or assess/design diagnostics will affect
an individual patient. We are taught that patients will not fit a set paradigm and that our responsibility is to offer them the best care available using the the art, the science and the practice of medicine. We are taught to trust our instincts and equip
them with the best evidence possible. I read 'How your doctor thinks' and there is nothing in there that we were not taught and expected to practice. In fact multiple discussions not just lectures and books occur on every module to make sure we get this and
learn the benefits and the limitations of EBM.
I find this quote particularly onerous
"On the other hand, I think something sinister is happening, mainly because of the striking circumstantial resonance between the reductionism of EBM and
the reductionism of contemporary policymaking".
Really??? We discuss policy making too and how reductionism can be eliminated and real science promoted and practiced. Why not enlist us to uncover the weaknesses and improve policy rather than toss us in the sea of blame. The blame mentality solves nothing
, creative insight and working together to solve problems does. If Dr. Greenhalgh thinks something sinister is happening why can she not use her considerable influence and intelligence to recruit others to solve the problem instead of just talk about it. Where
are her suggested solutions, do you think reading 4 books will fix it?
It is challenging enough to gently lead others into ways to find and apply best evidence without unwarranted pushback from Dr. Greenhalgh. It is sad
that she would allow one overconfident student to muddy the waters for the rest of us and define this as EBM. I really can see where she has gone wrong though, giving 4 books to a self confirmed by the book expert is a waste of space. He did not learn with
the patient and the physician right in front of him. He would be better sent to observe under supervision and with a gag order chronic, terminal and desparate patients and then sent to practical empathy classes until he is fit to practise.
Onwards and Upwards,
Amy
From:
Bruce Arroll <[log in to unmask]>
Reply-To: Bruce Arroll <[log in to unmask]>
Date: Monday, July 2, 2012 3:36 PM
To: <[log in to unmask]>
Subject: journal of primary health care and article on probabilitistic reasoning
Dear all
No doubt you have been following the vigorous debate over EBM with Trish Greenhalgh. It was in the latest edition of the Journal of Primary
Health Care. This is a medlined journal that is interested in high quality research and has a quick turnaround time for reviews. In it there is an article by myself et al on probabilistic reasonsing. We think we have pictorially linked pre-test probability
with the Fagan nomogram (and post –test probability). We developed this as a tool for teaching undergraduates although in my experience untrained graduates know little of the subject matter (potential conflict of interest I am on the editorial board of the
JPHC)
http://www.rnzcgp.org.nz/jphc-june-2012/
Bruce
Bruce Arroll MBChB, PhD,
FNZCPHM, FRNZCGP
Professor and Elaine Gurr Chair in General Practice
University of Auckland
Private Bag 92019
Auckland
New Zealand
ph 64-9-9236978
fax 64-9-3737624
email
[log in to unmask]
Physical address
School of Population Health room 378 building 730
Tamaki Campus
Corner Morrins and Merton Rd
Glen Innes
Auckland
From: Evidence based health (EBH) [mailto:[log in to unmask]]
On Behalf Of Amy Price
Sent: Sunday, 3 June 2012 4:17 p.m.
To: [log in to unmask]
Subject: Why an Evidence Based Approach
I am posting for Zbys as he got a reject from the listserve. His article makes some excellent on target points!
Amy
Surely its more than this i.e. ‘ bad’ research.. its also about “More or Less Healthcare research OR healthcare research more or less”
http://www.bahrainmedicalbulletin.com/june_2008/Editorial.pdf
Zbys Fedorowicz
Director
The Bahrain Branch of the UK Cochrane Centre
The Cochrane Collaboration
From:
Evidence based health (EBH) [mailto:[log in to unmask]]
On Behalf Of Amy Price
Sent:
Sunday, June 03, 2012 5:09 AM
To:[log in to unmask]
Subject: Re: Why
an Evidence Based Approach
I agree and a lot of 'treatment' is marketing and word of mouth. If it works it will work consistently blinded and with
controls. Anecedotes and experience are more fun and approachable than math and objectivity. The only reason I went in this field was because `I wanted true pictures for this I will even do the math even though I am no whiz. If people are not willing to pay
the price to do research right they need to enjoy a different field. The price for doing resarch wrong is lives, people and money
Amy
From:
Paul Elias <[log in to unmask]>
Reply-To: Paul Elias <[log in to unmask]>
Date: Saturday, June 2, 2012 9:48 PM
To: <[log in to unmask]>
Subject: Re: Why an Evidence Based Approach
because in many instances, experts are clearly wrong...its that simple. they dont know the hell of what they are talking about and making conclusions
that policy etc are based upon and the result is often morbidity and mortality...so some wise guy like Guyatt and Sackett and the like , maybe not the only thinkers on this, but decided enough of this and lets formalize and standardize the approach and put
some teeth into it...people die in the thousands due to decisions based on so called experts wracked with credentials yet just heresay and anecdotes...is this due to the treatment or intervention or due to chance? to answer this, one needs an evidence based
controlled systematic approach. yes, and large sample sizes and randomization to spread around potential confoudners and competing explanations...there remains so much uncertainty in all forms of research and inquiry...so many possible explanations...so we
need to control or mitigate the uncertainty and at the least, quantify it and account for it in an evidence based approach. my 2 cents... Best, Paul E. Alexander
I am trying to figure out why we need an evidence based approach and medical statistics . Or how best to explain it someone who is more convinced by
anecdotes and personal experiences. Or why did things like blood letting lasted for almost 2500 years. |