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Thanks for all these thoughtful emails. You are all so kind at helping think this through.

Yes Nik, Its the Hunink and Glasziou book that started my thinking and now you have reminded me I'm re-reading the last chapter and finding so much to include in my presentation.  

I'm trying to build a case for the receiver of evidence-based information rather than the giver of the information. We know the decisions won't always be predictable but if they are informed, with a minimum of bias, they will be right for the person. 

Michael and Neal, you have both described EBM being a journey. I like the musical analogy and the RNLI model showing EBM is not a fixed thing but something that is developing through discussions, evidence gathering and within ourselves. Hilda, there are some rules, or maybe techniques to guide us but as Amy has said, these will evolve too as we test interventions?

Using Myers Briggs will reach many in the audience who understand that better than EBM and find it baffling how some decisions seem illogical.  I think is also relevant that person-centred care seems to have evolved from Carl Rogers' work, even though it was about therapeutic change rather that care or medical treatments. Chapter 7 of 'Becoming a person' describes a process scale continuum along which individuals change from fixity to flowingness, when a relationship develops between the therapist and the client. 

This links with the idea of EBM being a journey which helps the development of a trusting relationship between the patient/ client and the practitioner - and my concerns about the potential risks in developing this relationship detached from a commitment to explain the evidence.

If we were to look at evidence of EBM influencing the receiver and helping their decision making process we might describe the change from fixity to flowingness as the development of self-efficacy and feelings of being in control of decisions? 

This might only apply in long-term conditions like type 2 diabetes, maternity care or interventions on behavioural change but I think it's the difference between doing something because society (or the person caring for you) expects you to behave in a certain way and making the decision to do it because someone has taken the time to explain it to you in a meaningful way even when it challenges your beliefs. 

Hunick & Glasziou sum it up beautifully: "The art of decision making is to integrate the evidence and values. The art of living is to integrate the head and the heart."


Phyll


On 10 May 2013, at 18:17, "Makretsov, Nikita [PH]" <[log in to unmask]> wrote:

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:EVIDENCE-[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]> 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