...good point, and precisely why I raised the question of
health techn. assessment and early warning systems in an
earlier email
Andrew Webster
"Greener, Jenny" wrote:
>
> How about refocussing the question away from the level of the individual
> patient - if there is no robust evidence of effectiveness for a particular
> service, should public money continue to pay for it?- perhaps a question of
> particular relevance in the UK NHS context.
>
> Jenny
>
> -----Original Message-----
> From: Stephen M. Perle, DC [mailto:[log in to unmask]]
> Sent: Thursday, May 02, 2002 5:49 PM
> To: [log in to unmask]
> Subject: Re: How do various specialities view EBM?
>
> Unfortunately you did not answer my question. I ask a genuine question and
> your
> response is flippant.. I know it is an anecdote, but if what I do is only
> placebo, how do I rationalize experiences like the one related? Does it
> seem
> likely that this was a placebo response? Doesn't placebo response require
> the
> patient to believe that the placebo is or could be effective?
>
> I understand what the literature tells us about the effectiveness of what I
> do. I
> know that at best it is equivocal and thus one must use their own judgment
> when
> confronted with a patient in pain. Isn't our current state of knowledge
> when it
> comes to the treatment of low back pain such that the evidence for any
> treatment
> is poor? So should I say to the patient, "You know research has not
> definitively
> found any treatment to help so suffer?"
>
> Obviously, the anecdote (which I know holds no probative value to the world
> of
> science) is my experience, thus it colors my judgment and pushes me off the
> fence
> to decide that lacking more definitive research I shall continue to use my
> best
> judgment and treat patients with the tools at my disposal. I say instead to
> the
> patient let's try a trial course of treatment and see if you respond. Is
> this
> not what Sackett (1) means when they say EBM is the best available external
> evidence, patient's desires and *doctor's expertise*? Or did I miss the
> meaning
> of doctor's expertise?
>
> 1. Sackett DL. Evidence-based medicine [editorial]. Spine
> 1998;23(10):1085-6.
>
> preston wrote:
>
> > Unfortunately you offer a typical response, nice anecdote!
> >
> > > I always tell my students that when you treat a patient and they feel
> better
> > > *after* they have left the office, they should always question was this
> > > placebo or natural history. But when one sees instantaneous responses I
> > > have less belief it is natural history but it could still be placebo.
> > >
> > > So from my personal experience let's look at a low back pain patient
> where
> > > the literature is much more equivocal. The patient barely walks into my
> > > office. I mean they walk bent over with their hands on their thighs to
> help
> > > hold up their body. They are obviously in extreme distress They have
> been
> > > suffering for two weeks with no change in Sx. They saw their M.D. and
> had
> > > both Rx NSAIDs and muscle relaxers which have had absolutely no effect.
> A
> > > friend twists their arm and makes them come to see the quack, er I mean,
> the
> > > chiropractor. I examine the patient and give them one manipulative
> thrust
> > > and concurrent with the thrust they are instantly pain free. (BTW this
> is
> > > an example of a relatively common occurrence) If this is a placebo, why
> > > didn't the medication work as a placebo? Why is the placebo a treatment
> > > that they absolutely did not want because they knew it would not work?
> > > Aren't placebo effective because the patient BELIEVES it will work?
>
> --
> _____________________________________________________________________
> Stephen M. Perle, D.C.
> Associate Professor of Clinical Sciences
> University of Bridgeport College of Chiropractic
> Bridgeport, CT 06601
>
> www.bridgeport.edu/~perle
> _____________________________________________________________________
> Ignorance more frequently begets confidence than does knowledge:
> it is those who know little, and not those who know much,
> who so positively assert that this or that problem will never
> be solved by science. Charles Darwin
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