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The discussion is indeed interesting, but simple dichotomy "EBM efficient" "EBM non-efficient" does not apply and is not quite testable. Some religious people don't need any proof of God, and I feel great about it. The compelling evidence that EBM is working is in the nature of EBM the methods of getting proof. Frequentist and Bayesian reasoning clash here, but the result is not a complete annihilation as some may insist, but the birth of a mechanism on how to transit from population research to individual patient level. The fundamental book of M.Hunink and P.Glasziou Decision Analysis in health and Medicine: Integration Evidence and Values is indeed a classic text and the compelling answer. Sure it is all about how to benefit the community with the most efficient medical interventions using the resources they have. Nik ________________________________ From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Hilda Bastian Sent: Friday, May 10, 2013 5:41 AM To: [log in to unmask] Subject: Re: EBM and Person-centred care - can you have one without the other? Hi there! Yes, I see what you mean. For me, the problem is partly that I think in this instance - EBM - "EBM" isn't a thing at all: it's more like a statement "music is a good thing and it should be one of the things that people consider when they want to be entertained, distracted or affected" and the adherents of that philosophy. If you try to separate "it" from the practices/actions/priorities it is encouraging, then I don't think there is any "thing" left. It becomes only a vague statement of belief - something like "the best evidence should be considered along with other things" where the meaning of the component words/phrases is interpreted differently/contested anyway. Embedded in the notion are things like "there should be more rationality and probabilistic thinking rather than going with the gut/(manipulated) flow in medicine". And "effects matter and things should be rigorously evaluated and those evaluations should influence what happens next." And of course, even without the articulation of something called EBM, those things existed. EBM then is characterized by its particular "things" - in particular, the systematic review, the trial, probabilistic statistics. What there is, is a lobby/community for particular types of changes to health research, health information, healthcare practice, health regulation/payment, health professional education etc, and the interventions being promoted that would make these things different to the way they would have been without a lobby for those changes. And if that lobby rallying around those changes that people want to see (very loosely categorized as "believing in EBM") hadn't existed, we would be better or worse off or no different, in different ways. Tried not to use the word paradigm, but really, isn't that what's left about what "EBM" is, if it's not its interventions and its lobby/community? This thing formed, but other things would have emerged if this hadn't existed. Maybe it's neither music nor performance: it's a kind of "rules" for musicians and audience, and its school of adherents, perhaps. Hilda On Fri, May 10, 2013 at 4:54 AM, Michael Power <[log in to unmask]<mailto:[log in to unmask]>> wrote: Thanks Amy and Hilda I was trying to clarify the difference between evidence on "the effects of EBM systems" and evidence on "EBM". To use a musical analogy, this is the difference between evaluating a performance and evaluating the music - hitting headlines this morning is the cancellation of a new production of Richard Wagner's Tannhauser. The problem was not with the music, but with the Nazi overtones in the production. Critics of EBM point out problems with the performance and make it seem that there are problems with the music - examples available on request. There is a similar problem with defining and explaining EBM. If you define or evaluate EBM by outcomes or applications, you are assuming that the performance IS the music. How will you improve your performance or develop a totally new production for your show? Changing the metaphor, I prefer to think of EBM more as a journey guided by the aspiration to make optimal decisions (our fixed star) than an itinerary with route and destinations that must continually evolve even if they were initially predefined. Michael