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Care is required because the EBM methodology and rationale reinforces the maximalist mindset
It is natural and makes sense to want to improve medical practice. And it seems to make perfect sense to want to intensify the application of the scientific method and EBM methodology to the problem of misdiagnosis. However, isn’t the sheer rationality of this quite scary, quite inhuman, as if beyond care?
This positivist EBM methodology has the same rationale that has led us from Halstead’s mastectomies, to national breast cancer screening programmes to Oncotype DX. And it is this EBM methodology and rationale that produces more interventions for the market. This reinforces the maximalist mindset that functions for capitalism to increase the economic productivity of life itself. But what is the aim of this EBM rationale today? Is EBM derived innovation aimed at reducing levels of iatrogenic harms already in existence, a damage limitation exercise, or to provide care that is harmless, or to make us live longer?
Remember that the policies of national screening, early referral, and predictive diagnostic interventions are aimed at prolonging, or to use the rhetoric, saving, life. They are the biggest cause of misdiagnosis and harm and, like austerity, are a matter of politicised choice. This preventive medicine is applied to, or imposed upon, the well. This kind of care goes beyond care. It is not the imperative, must do, kind of care needed for the present day suffering of the already unwell.
There are ways to use EBM to reduce iatrogenic harm and improve care.
Firstly, would be to actively identify and disinvest in flawed EBM practices, and not only, but especially, the least cost-effective.(Culyer et al, 2007) Flawed EBM practices would be those that fail to reach a much higher imposed burden of proof of benefit than currently exists. No longer imposed on the basis of possibilities, as with e.g. the UK NHS breast cancer screening programme (Baum, 2013), but instead ‘not commissioned til proven beneficial beyond reasonable doubt’.
This would, secondly, increase the options available to re-invest on and for for re-commissioning care that works (e.g. mental health services for the young, palliative care etc) and for practitioners to communicate with people.
Thirdly, the pressure to do this will be helped by insisting the teaching of EBM always includes a real world module on ideology and biopolitical theory. This would be Real Education for Real EBM, teaching the student practitioners about the way ‘the social’ interacts with real EBM’s most crucial object, namely, the diagnosis, and how capitalist ideology creates the maximalist mindset (Horton, 2017).
Baum, M. (2013) The Marmot report: accepting the poisoned chalice. British Journal of Cancer (2013) 00, 1-2, 00: 1-2.
Culyer, A., McCabe, C., Briggs, A., Claxton, K., Buxton, M., & Akehurst, R. (2007) Searching for a threshold, not setting one: The role of the National Institute for Health and Clinical Excellence. Journal of Health Services Research and Policy, 12(1): 3.
Horton, R. (2017) Offline: The Donald Trump Promise. The Lancet, 389(10087): 2360.
best
Owen
Juan
Another way forward to consider would be well planned large scale 'audits' of the performance of clinical findings, test results and treatments during routine care. Ideally, all doctors with suitable computerised records should participate.
This would allow the predicted probabilities of outcomes from RCTs and meta-analyses to be monitored and if necessary calibrated during day to day practice. It would also allow the performance of findings to be assessed for use in differential diagnosis, diagnostic criteria and prediction of treatment response.
Huw
-un saludo juan gérvas @JuanGrvas-we need less and best EBM, a new one with focus in outcomes from the point of view of patients/relatives and the society-yes, Owen, the problem is the ideology; an ideology that produces EBM products as in a factory (EBMfactorology, as riskfactorology) but usually do not care to much about translating the new knowledge and evaluating its impact in clinical care in patients' health outcomes (final health outcomes)-indeed, we usually consider an "ideal EMB" founded in RCT and meta-analysis
-but in practice the system does no work and we cannot trust most of the published EBM
Why Most Published Research Findings Are False
http://journals.plos.org/plosmedicine/article?id=10. 1371/journal.pmed.0020124 “Data fabrication and other reasons for non-random sampling in 5087 randomised, controlled trials".[hope, Kev, you find the references appropriate even being non-systematic reviews; i always try to do my best, i promise you]
https://forbetterscience.com/…/carlisles-statistics-bombsh…/
Low methodological quality/clarity of reporting of systematic reviews supporting clinical practice guideline. STEMI.
https://www.ncbi.nlm.nih.gov/pubmed/28623004#cm28623004_ 69715
2017-06-18 15:31 GMT+02:00 Huw Llewelyn [hul2] <[log in to unmask]>:
There is also a need to train the research community to do research that is more appropriate to support 'real EBM'. We have over-investigation because no evidence is sought to establish the best way of investigating differential diagnoses. We have over-diagnosis and medicalisation of health because no evidence is sought to establish valid diagnostic criteria. We have over-treatment because no evidence is sought to establish which patients will benefit.
As a result there is s free for all amongst those who wish to influence doctors. Some create evidence thin guidelines by exploiting EBM weakness to try to reduce expenditure. Others do the same to try to increase expenditure. What we need is 'real EBM' that addresses the real issues.
Huw LlewelynHospital Physician------------------------------
There may be a possibility for EBM to be rescued through the training of physicians and other health professionals in order to improve the dialogue and empower patient knowlegment.
Using empathy and risk communication to be able to share with the patient the decision-making of diagnostic and therapeutic procedures, based on the approriate evidence.
How many of us have already used this implementation strategy?
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Moacyr
_______________________________________
Moacyr Roberto Cuce Nobre, MD, MS, PhD
Equipe de Epidemiologia Clínica e Apoio à Pesquisa
Instituto do Coração (InCor) Hospital das Clínicas
Faculdade de Medicina da Universidade de São Paulo
55 11 2661 5941 (fone/fax)
55 11 991 331 009 (celular)
De: "Owen Dempsey" <[log in to unmask]>
Para: EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK
Enviadas: Domingo, 18 de Junho de 2017 6:31:43
Assunto: Re: Hijacked evidence-based medicine
Juan,
Your very useful analysis points us towards some of the most important processes that are contributing to healthcare harms and misdiagnosis.
I paraphrase your analysis here as key processes and possible key sites of intervention:
1) the education of healthcare workers,
2) the political (de-) regulation of harmful healthcare interventions (the ‘weak’ guidelines as they are euphemistically called),
3) the power of, and use of rhetoric by, experts (including e.g. GPs) to impose these on unsuspecting patients.
The belief of experts in the implementation of EBM is underpinned and dominated by a dominant rational positivist empiricism with a hat tip to ‘values’ (Howick, 2011). Because of this EBM has become a means of production for capitalism. And it is this, ideological, process that produces the predominantly maximalist and technologist mindset described by Groopman. This is the mindset that produces so much harm and misdiagnosis.
I suggest that EBM’s fatal flaw, the crisis of EBM, is the failure to consider that ideology in capitalism may be the site of formation of the mindsets, and therefore the values and beliefs, of both experts and patients (Greenhalgh et al, 2014; Kelly et al, 2015). And that it is the mechanisms of ideology in capitalism that requires analysis. But there is a kind of mental block resisting this.
Greenhalgh, T., Howick, J., & Maskrey, N. (2014) Evidence based medicine: a movement in crisis? BMJ, 348.
Howick, J. (2011) The Philosophy of Evidence Based Medicine. Chichester: Wiley-Blackwell.
Kelly, M.P., Heath, I., Howick, J., & Greenhalgh, T. (2015) The importance of values in evidence-based medicine. BMC medical ethics, 16(1): 69.
On Sat, Jun 17, 2017 at 4:36 PM, Juan Gérvas <[log in to unmask]> wrote:
-un saludo juan gérvas @JuanGrvas-EBM is a god that justify anything in its implementation-we need to be more critic with guidelines that have, as in this example, only 9–12% based on the best quality (Grade A) evidence https://www.ncbi.nlm.nih.gov/pand 3/ many doctors ignore the principal/agent theory and how to stand in "another's shoes" so they practice "defensive medicine" ("offensive" from my point of view)2/ many doctors do no know about their patients' culture, expectations and values http://pubmedcentralcanada.ca/-yes, Owen, apparently, EBM has only benefits without harms-but, how can we "believe" in the application of EBM in the consultation room, in front of the clinico/statistical tragedy
1/ many doctors do not understand health statistics http://library.mpib-berlin.mpg.de/ft/gg/GG_Helping_2008.pdf
pmcc/articles/PMC4484696/
mc/articles/PMC4245184/
2017-06-17 16:25 GMT+02:00 Owen Dempsey <[log in to unmask]>:
Isn't it the mindset of those in power that causes the issues, i.e. The misdiagnosis and harms caused by implementation of the products of EBM?
Hi Owen,
My point has always been there is a difference between Evidence based medicine (EBM) and the the implementation of EBM. Most of the criticisms which appears to be genuine criticisms of EBM are in fact criticisms of how it is implemented.
As you write, If indeed EBM is practiced in a different way and guidelines are promoted and institutionalized as standard of care, then let the editorial focus on exactly those issues. And this way we don’t have to spend time on re-inventing EBM and instead spend time and focus on actual issues that is at the core.
Also, none of the issues raised above will be solved by author's opinion of focusing on the co-called doctor's "mindset" approach. So once again we are just going in circles ignoring the actual issues.
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Un o’r 4 prifysgol uchaf yn y DU a’r orau yng Nghymru am fodlonrwydd myfyrwyr.
(Arolwg Cenedlaethol y Myfyrwyr 2016)
www.aber.ac.uk
Top 4 UK university and best in Wales for student satisfaction
(National Student Survey 2016)
www.aber.ac.uk