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Glad this is being brought up. A few years ago when I was researching the literature on applied behavior analysis for autism, I found something like 3 RCTs and 8 systematic reviews. (Obviously, performing RCTs with autistic children is a lot more difficult and time-consuming than just doing a systematic review.) Teresa Benson Clinical SME, Evidence-Based Medicine McKesson Health Solutions [log in to unmask]<mailto:[log in to unmask]> From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Juan Gérvas Sent: Sunday, October 23, 2016 4:31 AM To: [log in to unmask] Subject: Re: Check this paper...EBM a movement in crisis? -too little number of new RCT and to many systematic reviews and meta-analysis John Ioannidis. Debate about the abuse of systematic reviews and meta-analyses. John Ioannidis. Debate sobre el abuso de revisiones sistemáticas y meta-análisis. ¡Crecen + q los ensayos clínicos! https://www.ncbi.nlm.nih.gov/myncbi/john.ioannidis.1/comments/<http://cp.mcafee.com/d/avndy0Ad39J5wsejhhovd79ISyyCyYOC--yrhhjhupjsphdCPpJmNnWkH3BPtQjhOqehld3O0HuVEVhsKwMaWXoQsyH5ZYlQsgYlpQQsFKFLKuZpQSrdCPpesRG9pxjEm8iW1WLgAjUzkPyFq5y4I4qAUtaKMx92lehNtnUjFxISOeuudCXCQPrNKVJUSyrh> -un saludo juan gérvas @JuanGrvas 2016-08-28 23:34 GMT+02:00 Huw Llewelyn [hul2] <[log in to unmask]<mailto:[log in to unmask]>>: I was one of the contributors to this paper. I fully support the idea of EBM. I was taught by Cochrane as a student. The concept of EBM has always been embedded in me from the beginning. However, there are huge gaps in EBM as currently conceived. RCTs are performed without specifying the evidence for adopting the diagnostic tests etc used for choosing the patients to be entered into the RCT Andy the cut-off points for those tests. There seems to be a naive idea that the choice of 'gold standard tests' is self evident. It is a failure to address this issue that causes over-diagnosis, over-treatment etc. Another problem is that the differential diagnostic process and the choice of tests and other findings for use in it is not evidence-based. The differential diagnostic process is being ignored by EBM research. I explain in the Oxford Handbook of Clinical Diagnosis why Bayes simple rule with sensitivity and specificity / false positive rates is inappropriate for this process. Another theorem is required based on Bayes expanded rule and a dependence assumption. Until these and other issues are addressed, then EBM research as currently done will remain inadequate for my work as an experienced physician (and mathematician). Dr Huw Llewelyn MD FRCP Aberystwyth University Sent from my iPhone On 28 Aug 2016, at 14:32, Anoop B <[log in to unmask]<mailto:[log in to unmask]>> wrote: This article has been discussed here before. Most of the criticisms of EBM- although right- are just simply criticisms of scientific research and not a direct criticism of EBM. For example, the problem of doing research for profit, too much evidence, marginal gains and poor fit for multi morbidity. All these points towards the way research is carried out . EBM cannot control why and how someone does research and their motives. I feel like these criticisms should be specifically aimed at the conduct and reporting of research to gain any traction, like what Loannidis is doing. They are barking at the wrong tree , I feel. Also, most of their recommendations for improvement is what EBM has always recommended. For example, making patient care the top priority, share decisions, expert judgement and so forth. Remember the saying, 'evidence is not enough' is one of the critical motto's of EBM. Clinical rules without considering patient values and preferences is not and never was, EBM. Anoop On Sat, Aug 27, 2016 at 1:39 PM, Luiza de Oliveira Rodrigues <[log in to unmask]<mailto:[log in to unmask]>> wrote: I agree with that too. The guideline we made falls into the category of a) were developed primarily by, and definitely for, the people that ultimately end up using them b) were a credible synopsis of the best available evidence presented in a way that clinicians could easily access and interpret c) allowed patient values and preferences to be taken into account (not very explicitly, though... I will work on that!) But the resistance to it, I suppose, is exactly because of that... Some are arguing it is too "demanding" of solid evidence to make recommendations, when very little evidence exist. Which, of course, favors the industry-sponsored phase II RCTs of expensive drugs, that offer marginal benefits in non-comparative studies for a very specific profile of patients (such as brentuximab, ibrutinib and other drugs for lymphoma). Em sábado, 27 de agosto de 2016, Poses, Roy <[log in to unmask]<mailto:[log in to unmask]>> escreveu: I think we are in agreement. My point 2 below was similar, if much too brief. Guidelines derived from manipulated research without appropriately rigorous, skeptical review of same; that overemphasize published (maybe manipulated, maybe poor quality research) without taking into account that other research with different results may have been suppressed; and/ or developed by conflicted guideline panels, supported by institutionally conflicted organizations, using less than maximally rigorous, transparent, and unbiased procedures SHOULD NOT be trusted by clinicians. I believe many clinicians do not trust such guidelines, and hence appear "resistant" to them. Such clinicians should not be harried, but supported. On Fri, Aug 26, 2016 at 6:42 PM, McCormack, James <[log in to unmask]<mailto:[log in to unmask]>> wrote: Hi Roy - to be provocative, I think the following are a few reasons why clinicians in general (especially when it comes to chronic disease state guidelines) should be encouraged NOT to follow them - at least the way many of them are written at present. Obviously specific guidelines/checklists for things like surgery etc are very important but not so much for many other conditions. 1) No more than 10% of guideline recommendations are based on RCT data JAMA 2009;301:831-41, Arch Int Med 2011;171:18-22, Clin Endos 2013;78:183-90 2) Less than 0.5% of the words in guidelines for HTN, chol, glucose and osteoporosis relate to shared decision making or patient’s values and preferences when in fact these conditions are all about shared decision making Can Fam Physician 2007;53:1326-27 In my experience, guidelines rarely if ever provide clinicians with tools to help them make estimates of the benefits of treatments or the potential harms and guidelines rarely if ever are a systematic review of the evidence. See our comment about the latest diabetes guidelines - attached. Many people are very concerned about guidelines in general which is why I made the following video https://youtu.be/DHDnqQ_mCBA<http://cp.mcafee.com/d/FZsS82gQcCQm1MVd55xYQsCPqaaqbParXW9J55d5VBdNB4SrdCRr5vFiIendThd79EV5kQf82JXCzB5OW30HHJzhOaInTNnhN3NlDjhOCWC-VXRDjpISrdAVPmEBC5GJPrUx-1Mn3E2M3yGEAcy1ISOeuudCXCQPrNKVJUSyrh> HOWEVER - guidelines could be great if they a) were developed primarily by, and definitely for, the people that ultimately end up using them b) were a credible synopsis of the best available evidence presented in a way that clinicians could easily access and interpret c) allowed patient values and preferences to be taken into account We tried to do that with the first ever GP developed lipid guidelines - the major difference was that our guideline had thresholds for discussion NOT thresholds for treatment. http://www.cfp.ca/content/61/10/857.full<http://cp.mcafee.com/d/5fHCN0g4zqb0UsCyyM-qejpJ55d5VBdZZ4SyyCyYOCUOyrdCPqJyLQFm7bCXECzAQsyGq7A1mZPhOyVt1wlRSNEV5mbXUHEUxUGPFEVjtjvsZWPFISrdCM0lDlKJKmH2vMDzye8TNVYtPHpVVISOeuudCXCQPrNKVJUSyrh> Hope you find some of this of value/interest. James PS - I live in Vancouver and would love to catch up with your gang when you come to Vancouver for the conference if you think I could provide anything of value. I am, along with Richard Lehman, Paul Glasziou, Alan Cassels, and John Yudkin, doing a seminar at the Overdiagnosis conference in Barcelona at the end of September entitled "How clinical practice guidelines for chronic prevention could reduce overdiagnosis instead of promoting overdiagnosis" On Aug 26, 2016, at 11:14 AM, Poses, Roy <[log in to unmask]<mailto:[log in to unmask]>> wrote: I have helped give a course at Society of Medical Decision Making meetings about why physicians do not follow clinical practice guidelines. Although we do not have anywhere near as much data as we would like to support our findings, we do contend that the biggest problems are: 1 - physicians are pushed by extraneous values (in the language of decision psychology) or perhaps externalities (in the language of economics) to do something other than follow guidelines. In the US, these are often financial and bureaucratic incentives. 2 - physicians may have reasons to distrust the guidelines, including a - suspecting that the the evidence underlying the guidelines may have been manipulated or suppressed b - fearing that the guidelines themselves were not based on an optimal, evidence-based process, and may have been particularly biased by financial relationships of the people on the guideline panels, or the organizations that sponsored the guidelines. Here is a brief description of the version of the course that we will give in October in Vancouver: Dr Roy Poses and Dr Wally Smith will be teaching a short course on Sunday, October 23, 2016, at the annual North American meeting of the Society for Medical Decision Making<http://cp.mcafee.com/d/avndy0wrho73AQkm7PhOrdEEFELcFLLECQkkQnCkT6kjpISrlIl-BaMVsTt4QsCzAljgYwaTKqeknbEc2KKSd78GNvv5t74f5mtd7arGrXDLmtdCPpIS03EGwHM075v-sE4spuCjbX23uDBUlzcCnRnUOJI2WL_ek29ISOeuudCXCQPrNKVJUSyrh>, in Vancouver, British Columbia, Canada. The course title will be "Why Do Physicians Not Make Rational, Evidence-Based Decisions, and What Might Help?<http://cp.mcafee.com/d/2DRPoAcxMsrho73AQkm7PhOrdEEFELcFLLECQkkQnCkT6kjpISrlIl-BaMVsTt4QsCzAljgYwaTKqeknbEc2KKSd78GNvv5t74f5mtd7arGrXDLmtdCPpISjDdqymphl1nHlwXUvO-klglNeWbx2S02mzkz7ls6fFilo9IzDK1NISOeuudCXCQPrNKVJUSyrh>" We will emphasize: physician level factors, particularly the influence of extraneous values, such as perverse incentives, including conflicts of interest; problems with the evidence, including manipulation and suppression of clinical studies; and problems with ostensibly evidence-based clinical practice guidelines, especially the role of vested interests in constructing these guidelines. I submit that these issues ought to be addressed by anyone who seeks to persuade physicians to follow particular guidelines. On Fri, Aug 26, 2016 at 11:22 AM, Luiza de Oliveira Rodrigues <[log in to unmask]<mailto:[log in to unmask]>> wrote: Thank you, Juan. It is a fact that good quality evidence-based guidelines are lacking. But, still, how can we convince clinicians to pursuit them, if we also lack objective evidence (in terms of patient outcome and healthcare system effectiveness) that they are worth pursuing? There is a large investment (including financial) to create these guidelines. It takes time and a lot of effort, here in our HMO, to produce this material. It would be tremendously helpful and encouraging if we could affirm, with some degree of evidence-based confidence, that this is the path to better patient outcome and healthcare system effectiveness. As I put it before, I am convinced this is the best way of practicing medicine, but some people are not. They do accept that evidence summaries are helpful at the point of care. But they are not convinced that guideline-based decision making is any better than experience-based-evidence-informed decision making. And they scrutinize my convictions with the same standards that I scrutinize theirs, that is, asking me for the evidence to prove it. Fair enough, I think. Of course that we know how strong the industry influence is on specialists these days. I am not ignoring this fact. But still, I am grateful I had to ask myself these questions, because I am collecting the material you all kindly posted and it is already a consistent body of evidence. These replies have been very helpful and I thank you all! Thanks again! Regards, Luíza 2016-08-26 6:01 GMT-03:00 Juan Gérvas <[log in to unmask]<mailto:[log in to unmask]>>: -i agree with the critic but no with one argument: Too much evidence The second aspect of evidence based medicine’s crisis (and yet, ironically, also a measure of its success) is the sheer volume of evidence available. In particular, the number of clinical guidelines is now both unmanageable and unfathomable. -the problem is not of quantity but of quality -we have too much clinical guidelines of very low quality, without evidence -most clinical guidelines are just garbage -mos clinical guidelines are no EBM but "Eminence"BM, because industrial interest -for example Royal College of Obstetricians and Gynaecologists guidelines: How evidence-based are they? http://www.tandfonline.com/doi/abs/10.3109/01443615.2014.920794<http://cp.mcafee.com/d/FZsScxMQ721J5wsejhhovd79ISyyCyYOC--yrhhjhupjsphdCPpJmNnWkH3BPtQjhOqehld3O0HuVEVhsKwMaWXoQsyH5ZYlQsgYlpQQsFKFLKuZpQSrdCPo0auMgtH0-kfVv4aOPi5chLPadPhPBQm66n4n-jKyNNEVjKed7b1ISOeuudCXCQPrNKVJUSyrh> Eminence-based guidelines: a quality assessment of the second Joint British Societies’ guidelines on the prevention of cardiovascular disease, http://onlinelibrary.wiley.com/doi/10.1111/j<http://cp.mcafee.com/d/2DRPowcCQm1MVd55xYQsCPqaaqbParXW9J55d5VBdNB4SrdCRr5vFiIendThd79EV5kQf82JXCzB5OW30HHJzhOaInTNnhN3NlDjhOCWC-VXRDjpISrdw0WMfB3PV48X4JNyh_BKnN2IIhLOaaae29ISOeuudCXCQPrNKVJUSyrh>.1742-1241.2007.01310.x/full Diabetes. No significant impact of tight glycemic control on the risk of dialysis/transplantation/renal death, blindness, or neuropathy. But 95% of guidelines unequivocally endorsed benefit. http://circoutcomes.ahajournals.org/content/early/2016/08/23/CIRCOUTCOMES.116.002901.full.pdf?ijkey=hnQfo3zmmZFECR8&keytype=ref<http://cp.mcafee.com/d/FZsSczgOrho73AQkm7PhOrdEEFELcFLLECQkkQnCkT6kjpISrlIl-BaMVsTt4QsCzAljgYwaTKqeknbEc2KKSd78GNvv5t74f5mtd7arGrXDLmtdCPpIS03JadGJPn-DqjQhGT66DQU03BGMDY9V-NfboDt5PbLoCPwA6wIi30j18A61Iq6ehhsWZQPhPt7DmPP-mgt9i4iLBzys07tGOaaGwibzgA2TCww22LBFBBLezXFISOeuudCXCQPrNKVJUSyrh> Reporting of financial conflicts of interest in clinical practice guidelines: a case study analysis of guidelines from the Canadian Medical Association Infobase http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-01<http://cp.mcafee.com/d/FZsS76Qm1MVd55xYQsCPqaaqbParXW9J55d5VBdNB4SrdCRr5vFiIendThd79EV5kQf82JXCzB5OW30HHJzhOaInTNnhN3NlDjhOCWC-VXRDjpISrdw0O2JyvWvcDjUCo_jy4GG-xrUjzF_bVIpOIvZchLOabPCkhjd7ab9uW9ISOeuudCXCQPrNKVJUSyrh>6-1646-5 Financial Relationships With Industry Among National Comprehensive Cancer Network Guideline Authors http://oncology.jamanetwork.com/article.aspx?articleid=2546172<http://cp.mcafee.com/d/k-Kr4wUSyMe79EEIfCzASrhhjhupjvvhdEEFELcFKcECPpISHoHZalxOVKW9EVd78GCxV0lLsQsEKngo5ttIqehly--aWe8uaIWqekTkTTfuIWrdCPpI07m5GDR8BK4tlQ6CaNaYLCNDaN_Y3MYBIpOIvYA3ATS74hOpISOeuudCXCQPrNKVJUSyrh> -un saludo juan gérvas @JuanGrvas 2016-08-26 6:54 GMT+02:00 Dr. Yasser Sami Amer <[log in to unmask]<mailto:[log in to unmask]>>: Interesting article: http://dx.doi.org/10.1136/bmj.g3725<http://cp.mcafee.com/d/FZsSd39J5wsejhhovd79ISyyCyYOC--yrhhjhupjsphdCPpJmNnWkH3BPtQjhOqehld3O0HuVEVhsKwMaWXoQsyH5ZYlQsgYlpQQsFKFLKuZpQSrdCPo0d0fV2IK00UzvAkmnc8ayf4mhOrVISOeuudCXCQPrNKVJUSyrh> (via @Mendeley_com) @Luiza Dear Luisa, Greetings Did you read this paper EBM a movement in crisis? BMJ 2014 It discusses the same argument you have kindly raised here! Regards, Yasser Amer King Saud University Sent from Yahoo Mail on Android<http://cp.mcafee.com/d/k-Kr6xEg43qb0UsCyyM-qejpJ55d5VBdZZ4SyyCyYOCUOyrdCPqJyLQFm7bCXECzAQsyGq7A1mZPhOyVt1wlRSNEV5mbXUHEUxUGPFEVjtjvsZWPFISrdCOsVHkiPaCvypBVzxfySAWRVv5qA97_xbGhIs8ggzmi1ISOeuudCXCQPrNKVJUSyrh> -- Roy M. Poses MD FACP President Foundation for Integrity and Responsibility in Medicine (FIRM) [log in to unmask]<mailto:[log in to unmask]> Clinical Associate Professor of Medicine Alpert Medical School, Brown University [log in to unmask]<mailto:[log in to unmask]> "He knew right then he was too far from home." - Bob Seger -- Roy M. Poses MD FACP President Foundation for Integrity and Responsibility in Medicine (FIRM) [log in to unmask]<mailto:[log in to unmask]> Clinical Associate Professor of Medicine Alpert Medical School, Brown University [log in to unmask]<mailto:[log in to unmask]> "He knew right then he was too far from home." - Bob Seger -------------------------------------------------------------------- Un o’r 4 prifysgol uchaf yn y DU a’r gorau yng Nghymru am fodlonrwydd myfyrwyr (Arolwg Cenedlaethol y Myfyrwyr 2016) www.aber.ac.uk<http://cp.mcafee.com/d/k-Kr3zqb0UsCyyM-qejpJ55d5VBdZZ4SyyCyYOCUOyrdCPqJyLQFm7bCXECzAQsyGq7A1mZPhOyVt1wlRSNEV5mbXUHEUxUGPFEVjtjvsZWPFISrdCM0mAfzSSVIHxISOeuudCXCQPrNKVJUSyrh> Top 4 UK university and best in Wales for student satisfaction (National Student Survey 2016) www.aber.ac.uk<http://cp.mcafee.com/d/k-Kr3zqb0UsCyyM-qejpJ55d5VBdZZ4SyyCyYOCUOyrdCPqJyLQFm7bCXECzAQsyGq7A1mZPhOyVt1wlRSNEV5mbXUHEUxUGPFEVjtjvsZWPFISrdCM0mAfzSSVIHxISOeuudCXCQPrNKVJUSyrh>