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Dear all, Dr. Stanely makes an excellent point. In our course EBHC Oxford we have a module that addresses this and urges us to come up with materials that are usable on all fronts. Our knowledge in action component also stresses the importance of considering all the factors. What I find quite frustrating is the inconsistencies of numbers across country populations and the difficulty of integrating the qualitative information needed or to discern if it has been integrated at all in the literature particularly the systematic reviews. I am consistently having to go back to the original research rather than accept a review at face value. I think RCTs and systematic reviews are not equipped to deliver clinical expertise, they are tools in the hands of a clinical expert. I think it is difficult to extract information from sources that did not set out to include these factor in their outcomes. It would be good to explore ways to communicate this very important logic. Another aspect I would like to see to aid decision logic is experiential knowledge, if the process faces invisible barriers to implementation it is a lot of work for nothing. Public and patient stakeholders are starting to serve as advisors in research to promote positive change across multiple cultures and social climates. In the OMERACT initiative for example it was patients themselves who identified a state of exhaustion as a major consequence of Rheumatoid Arthritis though researchers had not noted this even after years of working together as an international collaborative. We at Thinkwell are working on an intiative to expand this process to other areas of research and diagnostics. Kirwan JR, Boonen A, Harrison MJ, Hewlett SE, Wells GA, Singh JA, et al. OMERACT 10 Patient Perspective Virtual Campus: valuing health; measuring outcomes in rheumatoid arthritis fatigue, RA sleep, arthroplasty, and systemic sclerosis; and clinical significance of changes in health. The Journal of rheumatology 2011;38(8):1728-34. Best, Amy From: Ash Paul <[log in to unmask]> Reply-To: Ash Paul <[log in to unmask]> Date: Sunday, August 12, 2012 12:34 PM To: <[log in to unmask]> Subject: Re: Can disclosure of financial conflicts of interest actually worsen bias? > Dear colleagues, > FYI (Message from Dr Donald Stanley). > Please see below > Regards, > Ash > >> >> >> >> >> From: donald stanley <[log in to unmask]> >> To: Ash Paul <[log in to unmask]> >> Sent: Sunday, 12 August 2012, 16:20 >> Subject: Re: Can disclosure of financial conflicts of interest actually >> worsen bias? >> >> >> Does anyone asking a treatment or diagnostic question distinguish between >> evidence for justification and evidence for discovery? I am thinking of the >> distinctions C. S. Peirce made between deduction, induction and abduction? >> The best we can do is look for justification from Rcts, but neither the >> optimal treatment decision, nor the correct diagnosis is answered, as pointed >> out by Ash; the decision is really another sort of intellectual logic not >> covered by EBM at all. Unless one takes Sackett's admonition to include >> individual clinical expertise as the answer. >> >> >> Dr. Donald E. Stanley >> Associates in Pathology >> 500 West Neck Road >> Nobleboro, Maine >> 04555 USA >> 207-563-1560 >> [log in to unmask] >> [log in to unmask] >> >> >> From: Ash Paul <[log in to unmask]> >> Reply-To: Ash Paul <[log in to unmask]> >> Date: Sunday, August 12, 2012 11:11 AM >> To: <[log in to unmask]> >> Subject: Re: Can disclosure of financial conflicts of interest actually >> worsen bias? >> >> Dear Huw, >> >> I'm really not sure how you can get this endemic problem solved by getting >> the right evidence to support opinions about the diagnostic and treatment >> criteria. >> It's all very good to have the evidence, but then you need the clinicians to >> actually follow that evidence, and that is something over which your Oxford >> Handbook has no control whatsoever. That finally boils down to a question of >> proper regulation by doctors and their professional bodies. >> >> Please have a read of this 2007 JAMA article: >> Ref: >> Cardiologists' Use of Percutaneous Coronary Interventions for Stable Coronary >> Artery Disease >> http://archinte.jamanetwork.com/article.aspx?articleid=769857#ref-ioi70093-12 >> >> Dr Grace Lin, the lead researcher of the 2007 JAMA study, has very recently >> been quoted in the Washington Post, and I quote: >> In 2006, a trio of medical professors gathered 20 cardiologists and asked >> them to discuss a hypothetical heart patient with a blocked artery and no >> symptoms. Removing the blockage would be riskier and costlier than giving the >> patient a few pills to take. The professors wanted to know: Would the >> cardiologists do the procedure? >> Yes, nearly all of them agreed. Yes, they would. >> “We had one physician say something I thought was pretty amazing. ‘We know >> the evidence shows not to do this, but we’re still going to,’ ” recalled >> Grace Lin, the lead researcher on the study at the University of California >> San Francisco Medical School. “There were some very strong financial and >> emotional biases towards going ahead with the procedure.” >> Ref: >> Inappropriate heart procedures are expensive and risky. And studies show >> thousands happen every year >> http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/08/08/inappropriate-he >> art-procedures-are-expensive-and-risky-and-studies-show-thousands-happen-ever >> y-year/ >> This article also reveals a medical term which I had never heard before viz >> oculostenotic reflex: >> Inappropriate cardiac interventions occur so regularly that a term for it has >> been coined in the medical literature: “Oculostenotic reflex” is defined as >> the “‘irresistible temptation” to expand narrowed coronary arteries, despite >> evidence-based guidelines” suggesting it shouldn’t be done. >> >> There is a huge scandal erupting right now in the USA, about USA's largest >> for for profit private hospital chain HCA, being investigated by Medicare for >> possible huge fraud relating to unnecessary cardiac work. The New York Times >> has recently published an article on this emerging scandal. >> Ref: >> Hospital Chain Inquiry Cited Unnecessary Cardiac Work >> http://www.nytimes.com/2012/08/07/business/hospital-chain-internal-reports-fo >> und-dubious-cardiac-work.html?_r=1&smid=tw-share&pagewanted=all >> >> In my opinion, it is high time for prestigious medical journals like BMJ, >> JAMA, Lancet and the Archives of Internal Medicine to carry out critical >> evidence based investigations into the entire field of interventional >> cardiology. >> The BMJ has already recently published an extremely critical article on the >> evidence-base for TAVI, which is now increasing by leaps and bounds in >> England. Scotland has fortunately resisted the introduction of TAVI, but my >> clinical colleagues in Scotland tell me that they are coming under huge >> pressure to introduce it in Scotland as well. The risk for having a stroke >> one-year post TAVI is also twice that following conventional surgery. >> They need to do the same for Atrial Appendage Occlusion (AAO) Devices, >> MitraClips, Renal Denervation for resistant hypertension and Patent Foramen >> Ovale Closure (PFOC) Devices, A nine year trial recently published on PFOCs >> has shown that the USA has spent 800 million dollars on this worthless >> operation, and not only is it not effective, but the mortality rates from >> this op are significantly higher. Apparently the clinicians were all >> operating on the basis of the theory of plausibility. This theory of >> plausibility in medicine needs serious investigating as well. >> >> Regards, >> >> Ash >>> >>> >>> >>> >>> From: Huw Llewelyn <[log in to unmask]> >>> To: [log in to unmask] >>> Sent: Saturday, 11 August 2012, 8:02 >>> Subject: Re: can disclosure of financial conflicts of interest actually >>> worsen bias? >>> >>> >>> The purpose of evidence is to try to validate opinions to foster informed >>> agreement. We desperately need evidence to support opinions about >>> diagnostic and treatment criteria. I think that this is the main cause of a >>> growing crisis in over-diagnosis and over-treatment, the controversy >>> surrounding the Diagnostic and Statistical Manual of Mental Disorders being >>> only one example of many. This issue is addressed in the Oxford Handbook of >>> Clinical Diagnosis’s Appendix, ‘Making the diagnostic process >>> evidence-based’ – ‘The logic of diagnostic criteria’, pages 751 to 754. >>> This appendix has been made freely available by Oxford University Press on >>> Amazon: >>> http://www.amazon.co.uk/reader/0199232962?_encoding=UTF8&page=41#reader_0199 >>> 232962. If anyone would like an Adobe copy of this Appendix, please let me >>> know. >>> >>> Huw Llewelyn >>> Aberystwyth University >>> >>> >>> >>> >>> >> >> >> >> >> >> > > > > > >