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I am struck by the different perspectives shown by this group, which includes epidemiologists, community and hospital doctors. Rakesh and I are hospital doctors who have been expected from our time as juniors to explain all our decisions ‘transparently’ to colleagues in hospitals and the community, including in clinic letters and discharge summaries. However when we see patients in busy clinics and wards we are expected to give opinions quickly based on non-transparent reasoning (or pattern recognition) based on ‘expertise’ in the same way as doctors in the community. It is subsequently that we have to give careful explanations +/- research evidence. In primary care, there is less demand to convince critical colleagues about every decision with transparent reasoning. Perhaps this quick non-transparent reasoning is roughly based on radical empiricism and the transparent reasoning is roughly based on logical empiricism. Epidemiologists focus on research evidence. Note that when justifying individual decisions we also apply the term ‘evidence’ to the individual patient’s individual symptoms, signs and test results. Therefore there are two types of evidence used in transparent reasoning: population and individual evidence (I call them general and particular in the Oxford Handbook of Clinical Diagnosis). It is common experience that when one tries to justify an initial non-transparent impression with transparent reasoning, their conclusions may not coincide. We then reconsider to avoid errors. In Allen’s analogy, each game of rugby is followed by a game of basketball; you have to win both to win the match. I feel that EBM as currently promulgated does not encompass all these and many other concepts, which is why there is so much controversy. Huw On 20 Feb 2019, at 02:43, Rakesh Biswas <[log in to unmask]<mailto:[log in to unmask]>> wrote: In our past discussions here, we may have created an EBM parlance labeling intuition as system 1 thinking (based on non transparent physician habits and experience) and slower critical rational appraisal as system 2 (based hopefully on transparent systematic reviews), apparently based on the work of Daniel Kahneman first expressed by him in 2003. Both these two systems of thinking allow us to operate on an unknowable plane where we perform our daily workflows, hoping to create our very own positive contributions and impact on the globe? The seemingly unknowable system 1 processes moving at a super speed are potentially knowable if we can freeze frame them into a slower storyboard (system 2). That appears to be a large part of the activity of healthcare researchers who spend their time collecting real time data to add to this current seemingly unknowable piece of large jigsaw puzzle that we can collectively witness in front of our storyboards (using search engines). Having said that there is nothing really in the universe that we can create. Whatever we create is just a reassembling of what already exists? best, rb On Feb 20, 2019 2:07 AM, "Wouter Havinga" <[log in to unmask]<mailto:[log in to unmask]>> wrote: Huw mentions non-transparent ‘thinking’ which is based on ‘personal expertise’, I think that aligns with experience. But not only past experiences but also that what is experienced in the moment, during the consultation. What I miss in EBM is the essential element for progress in any field, the personal experience, the experience the health care worker has in each consultation. Speaking as a family doctor, and taking the liberty to generalise, during the consultation we all have experiences in the interaction with the person who is consulting us. New discoveries are made by people having non-sense perceptible experiences, "intuitions". These new ideas (what Juan Gérvas called gut-feeling-based medicine) for approaches towards health should not be ignored, but can and deserve to be tested, so as not to get stuck in a particular frame of mind, like Huw says it "can be difficult to debunk later because of habit and pride." So I think more emphasis needs to be given to personal experiences during the consultation. In a previous post I discussed that with reference to a book by Rudolf Steiner (1) and by Thomas Nagel. (2) https://www.jiscmail.ac.uk/cgi-bin/webadmin?A2=ind1811&L=EVIDENCE-BASED-HEALTH&F=&S=&P=36019<https://emea01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.jiscmail.ac.uk%2Fcgi-bin%2Fwebadmin%3FA2%3Dind1811%26L%3DEVIDENCE-BASED-HEALTH%26F%3D%26S%3D%26P%3D36019&data=02%7C01%7C%7C568bdfaf6293482f614d08d696dd208a%7Cd47b090e3f5a4ca084d09f89d269f175%7C0%7C0%7C636862273810210549&sdata=UotAlnlBjEL2Zv9p%2F%2BsvR3ZpeRmzs4HgvFp%2F8ZSJc6g%3D&reserved=0> Steiner talks about one universal "thought content of the world" and Nagel calls it "the intelligibility of the world". We all are working towards a comprehension of this thought content of the world, but from different perspectives, which is why disagreements happen on the way towards this comprehension of the (universal) intelligibility of the world. Steiner and recently Nagel both described that science is the effort to come to the essence of things. In the search for that common understanding it might appear that subjectivity is taking over, but that can actually shift to objectivity. This shift from subjective to objective happens when it fits with what Thomas Nagel calls the intelligibility of the world. “It is not merely the subjectivity of thought but its capacity to transcend subjectivity and to discover what is objectively the case that presents a problem. Thought and reasoning are correct or incorrect in virtue of something independent of the thinker’s beliefs and the community of thinkers to which he belongs”. To be observant of one's own experience, call it intuition (which is non-sense perceptible) during the consultation, could add to one's past experiences and EBM knowledge and contribute to what Owen Demsey calls making the unknowable knowable. I hope that kind of non-sense perceptible component that happens when people meet, will be taken up in the debate, as Benjamin Djulbegovic mentions that "the debate is still very much alive". Wouter Dr W Havinga, locum GP, South West England @wouterhavinga 1 Rudolf Steiner, Goethe's Theory of Knowledge: An Outline of the Epistemology of His Worldview 2 Thomas Nagel, Mind and Cosmos: Why the Materialist Neo-Darwinian Conception of Nature is Almost Certainly False ######################################################################## To unsubscribe from the EVIDENCE-BASED-HEALTH list, click the following link: https://www.jiscmail.ac.uk/cgi-bin/webadmin?SUBED1=EVIDENCE-BASED-HEALTH&A=1<https://emea01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.jiscmail.ac.uk%2Fcgi-bin%2Fwebadmin%3FSUBED1%3DEVIDENCE-BASED-HEALTH%26A%3D1&data=02%7C01%7C%7C568bdfaf6293482f614d08d696dd208a%7Cd47b090e3f5a4ca084d09f89d269f175%7C0%7C0%7C636862273810220554&sdata=ngL3t%2Bffb9Dzzn9nFbe5LWuyGCkXfSxFyk%2F1o8%2FgtRs%3D&reserved=0> ________________________________ To unsubscribe from the EVIDENCE-BASED-HEALTH list, click the following link: https://www.jiscmail.ac.uk/cgi-bin/webadmin?SUBED1=EVIDENCE-BASED-HEALTH&A=1<https://emea01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.jiscmail.ac.uk%2Fcgi-bin%2Fwebadmin%3FSUBED1%3DEVIDENCE-BASED-HEALTH%26A%3D1&data=02%7C01%7C%7C568bdfaf6293482f614d08d696dd208a%7Cd47b090e3f5a4ca084d09f89d269f175%7C0%7C0%7C636862273810220554&sdata=ngL3t%2Bffb9Dzzn9nFbe5LWuyGCkXfSxFyk%2F1o8%2FgtRs%3D&reserved=0> -------------------------------------------------------------------- Prifysgol Aberystwyth www.aber.ac.uk Prifysgol y Flwyddyn ar gyfer Ansawdd Dysgu - The Times & The Sunday Times 2019. Aberystwyth University www.aber.ac.uk University of the Year for Teaching Quality - The Times & The Sunday Times 2019. ######################################################################## To unsubscribe from the EVIDENCE-BASED-HEALTH list, click the following link: https://www.jiscmail.ac.uk/cgi-bin/webadmin?SUBED1=EVIDENCE-BASED-HEALTH&A=1