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I just uploaded this document for you using Google Docs.. VIEW HERE <http://insuranceguru.com.sg/a/> Thank you. On Wed, Jan 15, 2014 at 2:32 AM, Amy Price <[log in to unmask]> wrote: > Thanks Michael, > > I was looking at the individual rather than the system values and > decisions as I find it is clearer to observe change through individuals > than systems. I learned this about myself on my first trip to assist > others in a developing nation. When I looked at them all as a group I > became overwhelmed with my small presence in the face of an overwhelming > cultural breakdown but when I looked at one person I knew I could help that > one. Sometimes the ones that change through individual communication are > themselves systems changers...and I will cheer for them and you but for the > present I shared the view from the corner I can visualize. When we add in > personal risk thresholds and time constrained values the options become > enough to make one dizzy. Interesting article on decisions in Nature > http://www.nature.com/news/why-irrational-choices-can-be-rational-1.14517 I do understand it is needful to consider both and how relationship > affects the system. I liked your illustration of the rowers and the anger > derailing the group/system direction too. > > I would like to expand your idea of teaching critical appraisal not only > to scientists but also the public especially since 50% of papers are now > Open Access and it would be better for all if they can be shown how to > apply what they read. For example I just read on Hilda Bastion's SciAm blog > where a commentator shared they were a secondary school instructor of > statistics and did not know what a meta analysis was....It looks like we all > have work to do changing minds and bringing light one person at a time or > through systems change or both depending on our unique areas of > communication, expertise and expression... > > Best > Amy > > From: Michael Power <[log in to unmask]> > Reply-To: Michael Power <[log in to unmask]> > Date: Monday, January 13, 2014 5:00 PM > > To: <[log in to unmask]> > Subject: Re: Real .v. Rubbish EBM > > Amy: I like your idea of a visual metaphor, but it needs to be a little > more complicated than a bicycle, because decision-making depends on > evidences and values - both plural. However English grammar forbids us to > say "evidences" because evidence is a mass noun, and mass nouns are so > fuzzy that they defy accurate visualization. > > > > The best metaphor I can imagine is a multi-player computer game in which a > boat is propelled by two parallel banks of rowers, one on the starboard > side and one on the port side -- BTW the ancient Greeks took this technology > to the limit with their triremes (http://en.wikipedia.org/wiki/Trireme), > which could have several hundred rowers. > > > > Players (representing values) control the rowers (representing evidences). > > > > Each player can adjust the force and direction of each rower's effort. > But, players (values) are not all equal. And rowers (evidences) are not all > equal. One or two players and one or two rowers will dominate -- this > represents our tendency to oversimplify. > > > > The sum of all the rowing efforts determines the boat's direction and > speed, and represents the decision; the final destination represents the > outcome. > > > > You can see how a Greek tragedy arises when two powerful values oppose > each other, or a Shakespearian tragedy when a dominant evidence and a > dominant value are not critically appraised - think of Desdemona's > handkerchief and Othello's jealousy -- the boat spins out of control and is > wrecked on the rocks. > > > > Ben: your brief history of EBM is useful. But I would suggest that we do > not ignore the parallel movements in improvement (and quality, and safety) > and implementation. EBM can learn from them, and vice versa. > > > > Kev: You are right to wave a red flag over hyperbole that could be > counterproductive if taken outside our debating arena. > > > > Rakesh, Neal, Zbys, Richard: thanks for your comments. > > > > A final suggestion: the way forward could include a step back (in time) to > re-emphasize critical appraisal of evidences, a step forward (in time) to > introduce critical appraisal of values, and another step forward (in > syncopated time) towards the Improvement, Quality, Safety, Implementation > movements. > > > > Michael > > > > > > > > *From:* Evidence based health (EBH) [ > mailto:[log in to unmask]<[log in to unmask]>] > *On Behalf Of *Amy Price > *Sent:* 12 January 2014 02:25 > *To:* [log in to unmask] > *Subject:* Re: Real .v. Rubbish EBM > > > > Hi Ben and all, > > > > What if we looked at evidence and decision making like two wheels on a > bike? They both need to be full of substance, well connected, lubricated > and working in balance with a competent driver with good vision on the > seat to get the vehicle where we want it to go? By the same rationale that > evidence is necessary but not sufficient for decision making, values are > necessary and default to feelings based on social pressures and peer > influence and lack focus without evidence and how to apply it. Maybe the > bike needs a check up and a little maintenance to run safely and at optimum > performance... > > > > I am hopeful that those who are time and location privileged so they can > attend this open event, will navigate well and come up with insights > together they would not have considered alone. It seems to me that what you > and others have pointed out for some time is starting to take root and > people are exploring ways to grow it out. I know I have considered this > carefully from the beginning after being privileged to enjoy the view from > yours and others experience and expression and I have thought yes I see > this but how can I best take it forward in the trenches. I hope there are > more conversations and collaborations so each one of us that cares can > have a part in the relationship as EBM continues to change health care and > history...Thank you for all you have done, reaching out to those new to the > evidence based way of thinking and your thoughtful papers, much > appreciated... > > > > Yours for evidence with informed decision making! > > > > Best > > Amy > > > > *From: *"Djulbegovic, Benjamin" <[log in to unmask]> > *Reply-To: *"Djulbegovic, Benjamin" <[log in to unmask]> > *Date: *Saturday, January 11, 2014 7:19 PM > *To: *<[log in to unmask]> > *Subject: *Re: Real .v. Rubbish EBM > > > > In trying to distinguish "real vs. rubbish EBM", have we come a full > circle? Some of us have pointed out for some time now that evidence is > necessary but not sufficient for decision-making. It appears to me that the > conference may end up confusing evidence for decision-making (and vice > versa). > > Ben Djulbegovic > > > > *From:* Evidence based health (EBH) [ > mailto:[log in to unmask]<[log in to unmask]>] > *On Behalf Of *Michael Power > *Sent:* Saturday, January 11, 2014 4:31 PM > *To:* [log in to unmask] > *Subject:* Re: Real .v. Rubbish EBM > > > > Hi Ruth > > > > Thank you for the open invitation to your meeting to define real and > rubbish EBM. > > > > If I had been able to attend, I would have offered the points appended > below. > > > > Best wishes > > > > Michael Power > > > > > > *Decisions, evidence, values, going off the rails* > > > > · Decision-making is at the heart of EBM, whether real or > rubbish. So, it would be useful to understand what types of decisions we > make, and how we do this. > > > > · EBM decisions are about the health and healthcare of > individuals or of groups. This classification is exhaustive and exclusive, > although guidelines try to span the boundary between groups and individuals. > > > > · All decisions, EBM or otherwise, are made on the basis of both > information (evidence) and emotions. The use of evidence is conscious; the > influence of emotion is usually subconscious. Emotions can outweigh what > rationally seems to be completely convincing evidence. > > > > · Emotions and values are intimately linked. When a decision is > in line with (or contradicts) a value, a corresponding emotion is felt and > guides the response. Values generally are learnt unconsciously and > involuntarily, but can be consciously taught and conscientiously learned. > > > > · Each of us has many different values, some of which are > contradictory, incompatible, or incommensurable. Think of "pro-choice" and > "pro-life". I (hopefully like most people) am for both. > > > > · Most people want to do a good job, but organisations and "the > system" can turn them into robots or petty box-ticking bureaucrats, more > concerned with process than outcomes. A few people are in it for themselves. > > > > > > *Decision-making in Personal and in Public health/care * > > > > There are notable differences in the use of evidence and the role of > values between EBM decision making in personal health and in public health. > > > > · *Evidence.* In public healthcare, statistical evidence from > groups can be confidently used to infer statistical outcomes for groups. > But for in personal healthcare we really want the individual's outcomes, > not those for a population. Bounded rationality (incomplete evidence, > imperfect reasoning) is a particular challenge when practicing personal > EBM, because our natural tendency is to oversimplify. For example, the > media tend to report just the direction of effect: a drug is beneficial (or > harmful). > > > > · *Values.* Values are important in both personal and public EBM, > but we need to be aware of the risk of not taking them fully into account. > This is particularly true for public health (and guidelines), because > decisions are tend to be made on economic values (or non-economic values > that have been monetized without considering what has been lost). > > > > · *Guidelines. *Guidelines should support real EBM, but can be > misused in rubbish EBM when box-ticking adherence to processes precludes > taking into account relevant personal values and evidence not mentioned in > the guidance. > > > > > > *Real vs Rubbish EBM* > > > > · Real EBM conscientiously critically appraises and takes account > of all the relevant evidence and all the relevant values in order to > support the patient or policy-maker to optimise their decision-making. > Rubbish EBM does not. > > > > · Clinicians practicing real EBM need to understand, and be able > to communicate to patients, not just the direction, but also the size and > importance of the average outcome (e.g. mean, or median, or mode); the > range of outcomes and shape of the distribution of outcomes (e.g. for > cancer prognosis; the typical long tail after the median); the risks of > mistakes, bias, blindness, and bullshit; and the risk of unknown unknowns > (much of the history of medicine is a series of cautionary tales about > unknown unknowns that should have been anticipated). Rubbish EBM does not > do this. > > > > · The values of real EBM are the reflected in a key aspect of EBM > leadership: to recognise an opportunity for improvement, and then to have > the gumption to (responsibly) do something about it. Rubbish EBM does not > see, or ignores opportunities for improvement. > > > > · Clinicians practicing real EBM need to be able to understand, > identify, elicit the relevant values in themselves, their patients, and > their culture. Rubbish EBM does not do this. > > > > · Rubbish EBM prioritises process over outcomes, means over ends, > the practitioner or organisation over the patient. Real EBM has its > priorities right. > > > > > > > > > > *The next step: prevention, diagnosis, and treatment of rubbish EBM* > > > > Once we have distinguished between real and rubbish EBM, we need to make > the next step, which is to prevent or to diagnose and treat rubbish EBM --- > even if this is not on the agenda for the meeting on the 14th. > > > > Most people want to do a good job, but organisations and "the system" can > turn them into robots or petty bureaucrats, more concerned with process > than outcomes. And, some people when given the opportunity, prioritise > their own advancement (prestige, income, comfort) over the quality of > service they render. > > > > On both sides of the Atlantic, and on either side of the equator, there > are major political and important professional initiatives to change > behaviour in healthcare systems by changing people's values. Generally, the > intervention seems to be a mantra-like repetition of a slogan such as real > EBM, Quality, Improvement, Patients first, Shared decision-making, > Affordable Healthcare, Payment by results, ... Theodore Marmor<http://www.asianscientist.com/books/wp-content/uploads/2013/05/6041_chap01.pdf>exposed the gap between this type of rhetoric and the reality: the slogan > is presented an effective force for improvement, but serial failures to > meet expectations, far from dampening wishful thinking, simply inspire > senior bureaucrats and policy makers to invent another slogan to promote > the next fad. > > > > > > Why has so little research on values been done (or at least published in > the types of journals Richard Lehman reviews). Why aren't the following > sorts of question being asked? > > > > · What values do people who wish to practice real EBM need to be > taught, to know, to apply, and to teach? > > > > · What is the optimal way of doing this? What is the role of role > models? > > > > · When someone who originally wanted to practice real EBM > develops into a practitioner of rubbish EBM, what unwanted values have been > gained, and what desirable values have been lost or subverted? > > > > · How can rubbish EBM be prevented, or promptly detected and > treated? > What factors create petty bureaucrats, inhibit responsible innovation, > foster organizational stupidity, promote self-seeking, and allow wilful > blindness and normalization of deviance? > > > > > > > > > > > > > > *From:* Evidence based health (EBH) [ > mailto:[log in to unmask]<[log in to unmask]>] > *On Behalf Of *Ruth Davis > *Sent:* 09 January 2014 15:45 > *To:* [log in to unmask] > *Subject:* Real .v. Rubbish EBM > > > > Tuesday 14th January 2014 > > 10:00 -12:30 (Coffee available from 09:30) > > Kellogg College, 62 Banbury Road, Oxford > > In September 2013 Trish Greenhalgh challenged Carl Heneghan to promote > 'real versus rubbish EBM' on Twitter. An example of rubbish EBM might be > (for example) putting a 75 year old on statins because the guidelines say > you should, with no account of their social situation, comorbidity, life > expectancy etc. Real EBM from a clinicians perspective would include taking > patient values and circumstances into account alongside evidence from > guidelines -and from an organizational perspective it would include > measures to avoid a managerialist, technocratic approach to promoting > guideline adherence. > > A meeting has been set up in Oxford with the aim is to define real and > rubbish EBM more rigorously. As part of this meeting there will be an open > session for all who would like to hear views on real v rubbish EBM from > the experts. > > > > Spaces a very limited, to register your interest please email > [log in to unmask] > > > > Titles include: > > Carl Heneghan - Why most research should not reach the appraisal step > > Paul Glasziou - Using healthy skepticism in the patient's interests > > Jeremy Howick - A new generation of bias in EBM > > Des Spence - EBM as a marketing tool for Big Pharma > > Neal Maskrey - It is not real versus rubbish, but EBM versus EBM2 > > Jon Brassey - An alternative system for systematic review production > > Richard Lehman - Patient Centred Evidence - the Unicorn that must be found > > Margaret McCartney - Too much treatment for the well, and not enough for > the sick > > Mike Kelly - Philosophical reflections on rubbish EBM > > Iona Heath - EBM is a means - but to what end? > > Ruth Davis > > CEBM Centre Manager > > Department of Primary Care Health Sciences > > University of Oxford > > Tel: 01865 289322 > > Tw: @CebmOxford > > *www.cebm.ox.ac.uk <http://www.cebm.ox.ac.uk>* > > > > >