Alistair

Your posting on statistics have been extremely interesting (and useful)
to me as a clinician

Cheers

Dave R

> -----Original Message-----
> From: alistair grant [SMTP:[log in to unmask]]
> Sent: 25 January 2001 23:15
> To:   [log in to unmask]
> Subject:      Re: The Myth of Homeostasis (former; currently rather:
> "Statistics in Physiotherapy")
>
> Perhaps I did not make myself clear about your attitude to statistics.
> Whilst I agree that I cannot experience your personal attitude towards
> statistics (which obviously is an animate process unique to you as an
> individual) I can comment that your 'attitude' in terms of how
> statistics
> are applied to everyday clinical situations and perhaps more
> importantly how
> you interpret statistical occurrence is not commensurate with the
> commonly
> accepted and widely practiced model of biostatistics that you may find
> in
> any standard medical or statistical textbook or indeed that you may
> question
> any competent bio/statistician on.
>
> Therefore the question is not whether I believe you are telling the
> truth or
> not but instead to challenge your assumptions and interpretations of
> statistics. This includes how you do (or perhaps don't) apply
> statistical
> conventions in your clinical practice and even more importantly the
> fact
> that you do not seem to be aware of the potential implications of your
> approach. Unfortunately you are not alone as the misuse, abuse or even
> omission of the important role of statistics in practice is endemic.
> Clinicians are 'clinicians' but they also require a sound
> understanding of
> these issues to deliver the best and most appropriate treatment to
> their
> patients. For a very good introductory overview to this issue read
> Chapter 1
> in Cambpell MJ, Machin D, Medical Statistics- A commonsense approach,
> John
> Wiley & Sons, 3rd ed in 1999.
>
> I fear that even having a research background is not a guarantee to
> understanding and appropriately applying statistical knowledge. If you
> do
> not agree with this I would ask you to seek any editor, statistical
> reviewer
> or internal/external referee of a peer reviewed biomedical journal and
> ask
> them how many papers they reject on the basis of statistical errors
> alone. I
> know for a fact that a sizeable proportion of papers submitted to the
> Lancet
> and the BMJ are rejected outright before they even reach the editorial
> team
> as the statistical referee gets first look to spot all the
> non-correctable
> statistical errors that render the paper invalid. This problem has
> also been
> given exposure in the literature in the various solicitations from
> those
> desperate for better research and better clinical care; see any of
> Trish
> Greenhalgh's work or Doug Altman's classic editorial in the BMJ
> (1994;308:283-284 - available on bmj.com).
>
> Therefore I do argue that your approach to statistics is harmful by
> the very
> nature of your approach which in postings to this list reveals several
> fundamental misunderstandings or mis-assumptions about statistical
> inference
> and interventions on both an individual and population level. Of
> particular
> concern is your continued belief that statistics does not concern
> itself
> with the individual- this reveals the extent of your unfamiliarity!).
> I
> continue to argue these points as they apply to real patients in real
> time
> and although may be conceptualised (just like states of health and
> disease
> which is why we are in clinical practice) they are most definitely not
> limited to just theoretical or philosophical debate.
>
> I work within a major University department of the UK NHS R&D
> programme and
> I am a strong advocate, like all my colleagues are, of improving the
> quality
> of i) health services research and ultimately through this ii)
> clinical
> practice (which is the whole point of doing research!). Inherent in
> this
> quality improvement process is an appropriate, an enlightened and a
> reasoned
> approach to at least understanding the clinical decision making
> process from
> a perspective other that of 'clinical blindness' or 'clinical tunnel
> vision'. Your approach to statistics does not appear to endorse this.
> Unfortunately this discussion list is not an appropriate medium for
> illustrating these important issues in further detail (and I fear our
> quibbles must be growing tiresome for our colleagues on the list)
> however
> perhaps I could suggest you investigate the excellent UK Health
> Technology
> Assessment Methodology Monographs (available online at
> http://www.hta.nhsweb.nhs.uk) and also the high quality Cochrane
> Collaboration Methodology Register which is now widely available
> (although
> you will need a password for the online version) which contain a
> series of
> papers that explain in detail but with clarity these points.
>
> Whilst I suspect that you may never embrace the statistical concepts
> that I
> have attempted to outline here I do urge you to consider more
> carefully your
> somewhat reckless approach to clinical decision making. Like it or not
> or be
> aware of it or not your decisions and the process by which you get to
> those
> decisions have implications on your patients. I think Gina Radford,
> one of
> the first directors of the UK National Institute for Clinical
> Excellence
> (NICE) summed it up when she said "nobody in healthcare goes to work
> to do a
> bad job". Of course how you interpret whether somebody is actually
> doing a
> good job or not is the fundamental premise of what we are debating...
>
> Alistair Grant
> Institute of Public Health
> University of Cambridge
>
>
>
> >From: "Stanislav A. Korobov" <[log in to unmask]>
> >Reply-To: PHYSIO - for physiotherapists in education and practice
> >    <[log in to unmask]>
> >To: [log in to unmask]
> >Subject: Re: The Myth of Homeostasis (former; currently rather:
> >  "Statistics in Physiotherapy")
> >Date: Tue, 23 Jan 2001 12:11:39 +0000
> >
> >You wrote: <Unfortunately I cannot agree with your claim that you
> >&ldquo;have a respectful attitude towards statistics including
> statistics
> >in
> >biomedicine&rdquo;.>
> >
> >Your claim about my claim seems to me strange. You can agree or
> cannot
> >agree
> >but my attitude is mine. If I have an attitude to a thing, then I
> have it.
> >And if I say that my attitude is respectful, it means that I feel and
> deem
> >and assess it exactly so. Respectfulness, as far as I know English
> words,
> >is
> >a sense. Excuse me, do you know my senses better than I do? Your
> inability
> >to agree with my claim is meaning for me only one thing -- you do not
> >believe that I told the truth about my sense. Interestingly...
> >
> >I am forced to repeat: my attitude to statistics in biomedicine is
> >respectful. Even very respectful. The main reason of this is probably
> my
> >researcher's background. I had many statistical calculations when
> dealt
> >with
> >the results of my investigations. And I saw, of course, that
> statistics is
> >an useful tool, and in order to make a generalized conclusion as to a
> group
> >of objects we cannot dispense with statistics' assistance. And that
> >statistics often helps us to see such things that are hidden if each
> object
> >is considered separately.
> >
> >However I think that YOUR misunderstanding the situation is that you
> >attempt, as far as I can coclude from your texts, to look at any
> separate
> >phenomenon as a particular case of an appropriate distribution curve.
> I
> >think it is a mistake. Any curve obligatorily has the restrictions
> due to,
> >at least, the initial mathematical assumptions and the limited
> quantity of
> >observations taken into consideration. In principle, you can make any
> your
> >statistical conclusion only in regard to those particular points
> which do
> >form this curve! Any additional (new) points need, first of all, to
> be
> >proved as those pertinent to this curve. Are you sure that any new
> object
> >is
> >condemned to fall within the curve (no matter -- at tails or at the
> >middle)?
> >If yes, you risk to make the fatal for this object mistake. Of
> course, a
> >likelihood of such event may be negligible but it always exists!
> >
> >Your mistake is also a philosophical one. Indeed, dialectics does
> teach us
> >that there are unity and struggle of contraries. One thing is
> >simultaneously
> >general and particular, big and small, bad and good. As to the
> subject of
> >our discussion, each our separate patient or his/her separate index
> is
> >simultaneously belonging to the whole population and strictly
> individual! I
> >think you will agree that EACH given organism is definitely unique
> and its
> >combination of components is non-replicated. If so, have you a right
> to
> >look
> >at this organism as one of known-to-you points of the curve (even of
> those
> >of its tail)? I suppose you have not such a right. You may only
> ASSUME that
> >this object MAY belong to the group of those known points. To
> determine
> >definitely whether this is true you need to make ALL accessible
> particular
> >measurements and calculations, and only AFTER this you have grounds
> to say
> >PRESUMABLY about such belonging. As well as grounds to make a
> clinical
> >decision (keeping permanently in mind that you are about a failure of
> this
> >making!). Consequently, when you are at the beginning of dealing with
> a
> >patient and his/her data you are only AROUND the curve but not
> oligatorily
> >at it (surely a likelihood of all appropriate events may be more or
> less;
> >it
> >is already a quantitative aspect of the problem; I am interested more
> in a
> >qualitative analysis of the situation). So you should be very careful
> with
> >regard to your conclusions based on your knowledge of appropriate
> >statistical curve. Otherwise, you risk to make an unpredictable
> clinical
> >error.
> >
> >You write about contradictions in my line of argument. The drama is
> that
> >the
> >life is contradictive in all its aspects! In ALL. It seems, our world
> was
> >initially made contradictive. If you deem that you have not
> contradictions
> >in your past, present or future considerations, a disillusion does
> wait for
> >you.
> >
> ><Your attitude to separation of statistical interpretation in
> clinical
> >trials and the clinical decision making process is harmful...>. I
> really
> >separate these things (although they have close relations, of
> course). You
> >may see above -- why. And I think that uniting these processes is
> more
> >harmful because it gives a temptation to classify easily (but a
> priori) a
> >clinical case as such that conforms to the results of above-mentioned
> >trials. This is a huge mistake. In a given case, we can only assume
> that
> >such conforming is possible with a certain likelihood.
> >
> >Statistics really does not take an interest in a separate individual.
> If
> >you
> >think otherwise, please provide me with an example of statistics when
> n=1.
> >Statistics needs in many (or, at least, several) individuals or
> individual
> >indices to make its conclusions. Isn't? Hereof is my statement that
> >statistics cannot live without groups of digits of the same kind (I
> meant
> >groups of results of uniform measurements; sorry if my English is
> >incorrect).
> >
> ><John Smith as a &lsquo;sample&rsquo; of the wider population must
> lie
> >somewhere within a distribution curve...>. Why MUST?? About 15 years
> ago I
> >had a patient who MUST rise his body temperature when I treated him
> with
> >large applications of warm peloid (mud). At least, the most of people
> did
> >exactly so. But he was not wishing to rise it. Absolutely. And I do
> not
> >know
> >why up to today (methodical failures are rather excluded since we had
> >measurements repeated using different investigators and different
> patients
> >to compare). Maybe he was without of all known laws of physics?
> Hardly.
> >Then
> >why? Maybe because he was, using your words, from the tail of the
> curve?
> >Maybe. However I have not a relief  from such an 'explanation'. And
> should
> >I
> >look at him as a point of that curve (even -- from its tail, or the
> end of
> >the tail) I would get his heat shock definitely.
> >
> >Perhaps your key misunderstanding is best reflected by the following
> your
> >words: <this is not a &lsquo;philosophical&rsquo; situation but a
> real life
> >situation>. Until you have misunderstood that EACH our 'real life
> >situation'
> >is exclusively a philosophical one, you will make a mistake of too
> >schematic
> >(mathematical, formalizing; at any event -- simplifying) look at a
> >phenomenon. Unfortunately (fortunately?) the life is wider and deeper
> and
> >--
> >it is also obvious -- less understood than ANY its statistical
> description.
> >Even -- generated by the best unit in Europe or in the world.
> >
> >I think we, clinicians, should indubitably use all available
> statistical
> >data and approaches relevant to our separate clinical cases. But we
> MUST
> >make our crucial clinical decisions only using all our opinions,
> senses,
> >experiences and intuitions.
> >
> >Stanislav A. Korobov, MD, PhD
> >Physician-Physiotherapist
> >'Mountain Air' Study,
> >'Lermontovskii' Clinical Sanatorium.
> >PO Box 7, Odessa, 65089, Ukraine
> >[log in to unmask]
>
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