I think that editorial is just a mis-characterization of EBM. What modern EBM advocates is that when the evidence is grey or uncertain or weak, patient values and priorities should take precedence. In fact, that "there is no single right answer for everyone" as written in the article is exactly what EBM advocates ever since EBM originated. Can anyone point me where EBM contradicts this? So the focus should be on the patient's "mindset" rather than on the clinician's "mindset" as the editorial says.
In fact, 2/3 of the evidence summaries in Uptodate is classified under weak recommendations. So when the guidelines is mixed, it simply reveals shows that the evidence is weak and recommendations should be highly individualized or values and preferences should take center stage. Guyatt himself have written articles criticizing the use of guidelines without looking at patient values and preferences.
Also, part of the problem is different instutns using different grading schemes. EBM and a lot of others uses a GRADE approach, while USPSTF has their own grading system. If we can have one grading system, most recommendations would be pretty consistent, I think.
On Fri, Jun 16, 2017 at 12:40 PM, Owen Dempsey <[log in to unmask]> wrote:This is brilliant Juan, thank you.Hortons' editorial is a timely invitation to reconsider the mechanisms by which ideology forms our values and prompts us to ask 'Howis our mindset determined?"Three of the extremes of the dimensions of the mindset conceptualized by Groopman are consistent with the three elements that make up the fundamental structure of the ideology we call capitalism. These are, a) the faith in b) technological innovation to create c) surplus value. And these are paraphrased by Groopman under the dimensions of: belief, technology and maximalist.
However instead of being spread out evenly along these dimensions the capitalist system tends to polarise these mindsets in one direction only. And individuals' values and mindsets aren’t each just spread along the axis evenly, but are instead also polarised. In capitalism the polarity is driven by the belief in technology to take life ‘to the max’. This is a description of how the structure forms our mindset, where it is not only surplus profit that motivates but as we know the drive to surplus life. It is this structure that dominates the mindsets of the experts/industrialists/politicians controlling what is produced by science, and what is marketed and consumed.
As we know, the clinical decision at patient level is increasingly dominated by (so-called Evidence Based) guidelines, which, as a rule, mostly command compliance and defensive medicine. Therefore individual clinician’s or patients have only limited impact on these decisions when compared to the guideline producers. So we could focus more attention on the marketisation of innovation, the production of guidelines and the intensification of e.g. prevention and screening programmes. At the same time we could be more sceptical at individual level but to resist demonisation and medico-legal sanctions, this would require some solidarity and collective action. A resistance mission would ask for 'sceptical healthcare' characterised by, a) less belief in, e.g. expert appraisals (much more rigorous standards of proof of e.g. lack of harm as well as benefit, b) less reliance/emphasis on innovation (whilst not denying its potential), and c) less emphasis on maximalist goals for life (especially longevity) and more emphasis on life-lived (today) and, d) increased ambiguity about compliance with guidelines. As individuals how much difference can we make? Not much. Important questions are: How can we challenge the power of scientific practice and industry to continue enforcing the de-regulation of marketisation and the destruction of the public heathcare systems through privatisation?
read more/ ...........................................
Capitalism's logic of fantasy requires: a) the loss of belief in the impacts of misdiagnosis, b) the deregulation of industry so that it can provide an endless supply of technology that c) secures our belief in its promises of the one thing we are made to feel lacking, namely d) surplus life-security, and d) the society (here, markets, healthcare systems and science) that offers enough people the opportunity to consume their products to make profits.
The loss of belief is necessary to foster belief and a mindset. It is the loss of 'received meaning' (i.e. that is to say, the loss of impact on behaviour) of the sacrifice of the many for the few. But how is this achieved, how is a collective mindset nourished? This, I think, is achieved by stabilising belief and mindset through the use of language, especially by mainstream media, experts, industry, and governments. In their speech meaning for language is achieved by attaching their rhetoric to certain key motifs: for healthcare these include for example: breakthrough/innovation is meaningful, survival/longevity/lives-saved from cancer are meaningful, premature death is meaningful, productivity is meaningful, sensitivity (of tests) is meaningful, prevention is meaningful, molecular/personal is meaningful etc.
Best wishes
Owen
Owen Dempsey MRCGP UK
--On Fri, Jun 16, 2017 at 11:52 AM, Juan Gérvas <[log in to unmask]> wrote:-Richard Horton has his own opinion:-un saludo juan gérvas @JuanGrvas
Their point was that most clinical decisions lie in a grey zone—there is no single right answer for everyone. The important step is less to adhere to some abstract notion of EBM, but rather to think hard about what kind of medical mindset you have. Whether you are a maximalist-believer or a minimalist-doubter will have a larger effect on your clinical decisions than the result of any single systematic review or randomised trial. We see these mindsets at play all the time in today's scientific, evidence-informed medicine. There have been at least four US expert committees ruling on the safety and efficacy of screening mammography—with four different sets of recommendations. There have been three expert committees reviewing the evidence on screening for prostate cancer using PSA—with three different conclusions. So much for science. So much for evidence. What matters more are the mindsets of those “experts” reviewing the scientific evidence. Here is The Donald Trump Promise, according to Groopman and Hartzband. Modern scientific medicine promises the right doctor prescribing the right treatment and the right procedure for the right outcome. It's just impossible. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31657-4/fulltext2017-06-16 7:08 GMT+02:00 Jordan Panayotov <[log in to unmask]>:To paraphrase Ioannidis, while being on the same page, I fully agree that:Academic publishing has become a business, mostly serving vested interests of:No.1 Publishers , making $$ billions every year by (illegally) claiming copyright to public intellectual property (most research is funded by the public, thus the 'product' belongs to the public, and not to researchers who do not have right to assign copyrights to the publisher!) For example, I have to pay US$ 35.95 just to see this paper!?!No.2 Medical/Pharma industry that sell their products for $$ billions every year (remember Tamiflu?), based on the "Evidence" from published papers.No.3 Academic researchers who get public money (grants) based solely on number of their publications.Apparently, today academic publishing has deviated so significantly from it's originally declared goal - to disseminate knowledge, that almost nothing of this goal has remained.Disseminating knowledge has become a collateral benefit for few, while serving the main goal of maximizing income/profit of the three beneficiaries above.For example, I have to pay US$ 35.95 just to see a paper!?!Who benefits out of this totally corrupt way for disseminating knowledge?Answering this question can set the right fundament for designing a new way for disseminating knowledge, which will bring the EBM to it's original purpose.Jordan
From: Anoop Balachandran <[log in to unmask]>
To: [log in to unmask]
Sent: Thursday, June 15, 2017 8:18 AM
Subject: Hijacked evidence-based medicine
New article from Loanniddis : Hijacked evidence-based medicine: stay the course and throw the pirates overboard.The article discusses a number of criticisms that have been raised against evidence-based medicine, such as focusing on benefits and ignoring adverse events; being interested in averages and ignoring the wide variability in individual risks and responsiveness; ignoring clinician-patient interaction and clinical judgement; leading to some sort of reductionism; and falling prey to corruption from conflicts of interest. I argue that none of these deficiencies are necessarily inherent to evidence-based medicine. In fact, work in evidence-based medicine has contributed a lot towards minimizing these deficiencies in medical research and medical care. However, evidence-based medicine is paying the price of its success: having become more widely recognized, it is manipulated and misused to support subverted or perverted agendas that are hijacking its reputation value. Sometimes the conflicts behind these agendas are so strong that one worries about whether the hijacking of evidence-based medicine is reversible. Nevertheless, evidence-based medicine is a valuable conceptual toolkit and it is worth to try to remove the biases of the pirates who have hijacked its ship.I have wrote this quite a few times in this forum: Most of the criticisms against EBM are not actual criticisms of EBM, like EBM ignores the patient, conflict of interest and so forth. Glad to see the article since many people were using his articles to chastise EBM.