Nice BMJ article Anna !

I must confess I did a Masters module in EBP a few years ago and found it to
be one of the most enduringly useful bits of studying that I have done,
because it helped me to learn how to search and evaluate literature and
differentiate between different types of evidence . It also made me realise
that wherever there is a personal interaction in a therapeutic event (ie
everything we do day to day) qualitative research is likely to be more
illuminating than quantitative studies. It is relatively easy for medics to
trial a magic pill ; add a person to the equation and the data gets confused
!

So study the literature, it gives us ideas - but is the combination of
literature knowledge plus our clinical experience that counts - hopefully
this is the message our students are coming out from their training with
now.

Nikki Adams   [log in to unmask] Original Message -----
From: "Anna" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, February 05, 2003 7:03 PM
Subject: Re: evidence based practice


Hello,

I have been following the discussion with great interest. I have my views
about those who are blinkered in thinking RCTs are the only solution to the
profession's survival, credibility, efficacy, attraction etc etc.

I thought this little article I found in the BMJ might give some of you a
chuckle after this seeeeeerious discussion!

if the photos don't come out on your screen, it would be worth getting the
original and having a look, they are a lot of fun

For those of you whose English is not their first language, the Macquarie
Dictionary defines crap (a colloquial term) as [noun] 1. excrement;
2.nonsense, rubbish; 3. junk, odds and ends; [verb] 4. to make a mess of,
bungle;  5.annoy, disgust; 6. to defecate;  7. to talk nonsense (crap on);
8. to fail (crap out)
BMJ 2002;325:1496-1498 ( 21 December )



EBM: unmasking the ugly truth
Clinicians for the Restoration of Autonomous Practice (CRAP) Writing Group.

Correspondence to: CRAP Writing Group, Poste Restante, London WC1H 9JR

One morning we found a strange notice nailed to the door of the BMJ. On
checking their email, all BMJ staff found the full, illustrated version of
this report

Clinicians for the Restoration of Autonomous Practice (CRAP) has written
this report and nailed it to the door of the BMJ. We have done this
anonymously and under cover of darkness to protect ourselves from
retaliation from grand inquisitors in the new religion of Evidence Based
Medicine (EBM). Our report is based on documents liberated by undercover
agents who have successfully infiltrated the EBM movement to uncover the
truth about EBM, its hidden agenda, and the shadowy forces behind it.
Despite repeated denials by the high priests of EBM that they have not
founded a new religion, our report provides irrefutable proof that EBM is,
indeed, a full-blown religious movement, complete with a priesthood,
catechisms, a liturgy, religious symbols, and sacraments. We can confirm
that proselytisation is now occurring on a global scale and threatens the
very existence of for profit, doctor centred, authoritarian medicine as we
know it. CRAP has issued this rallying call to all who wish to conserve our
traditional values.


            10 commandments

CRAP has long suspected that EBM secretly espouses cookbook medicine, based
on a blind faith in "methodology," the alchemistic philosophical basis for
this religion. We can now confirm the existence of an EBM bible and
catechisms, which were discovered by chance when one of our members removed
the mini CD Rom from a recently published EBM textbook and played it
backwards. The 10 commandments of EBM, which were reportedly delivered as a
printout to a prophet on Mount Hamilton, were presented against a musical
background ("All you need is trials"):

  a.. Thou shalt treat all patients according to the EBM cookbook, without
concern for local circumstances, patients' preferences, or clinical judgment
  b.. Thou shalt honour thy computerised evidence based decision support
software, humbly entering the information that it requires and faithfully
adhering to its commands
  c.. Thou shalt put heathen basic scientists to the rack until they repent
and promise henceforth to randomise all mice, materials, and molecules in
their experiments
  d.. Thou shalt neither publish nor read any case reports, and punish those
who blaspheme by uttering personal experiences
  e.. Thou shalt banish the unbelievers who partake in qualitative research,
and force them to live among basic scientists and other heathens
  f.. Thou shalt defrock any clinician found treating a patient without
reference to all research published more than 45 minutes before a
consultation
  g.. Thou shalt reward with a bounty any medical student who denounces
specialists who use expressions such as "in my experience"
  h.. Thou shalt ensure that all patients are seen by research librarians,
and that physicians are assigned to handsearching ancient medical journals
  i.. Thou shalt force to take mandatory retirement all clinical experts
within a maximum of 10 days of their being declared experts
  j.. Thou shalt outlaw contraception to ensure that there are adequate
numbers of patients to randomise.






           Fig 1.   The Cochrane symbol, seen here in plans for the façade
of the Cochranite Vatican that is to be built in Summertown








Much of what is written in the EBM religious tracts can also be found as
catechetical instruction in seemingly innocuous sources, such as the
Cochrane Handbook and the CONSORT statement.



       Religious symbols of EBM

Symbolism within the EBM religion has developed rapidly. This may be due to
the fact that the religion is actually all "old hat," as some brave critics
have pointed out. Many symbols have been stolen shamelessly from other
religions. The EBM cube, for example, was stolen from the Rubricons, and the
Cochrane logo that appears not only in print but also as "crop circles"
across the countryside seems likely to have been based on an ancient
pharaonic pictograph (see fig 1).

One of the most frightening discoveries by CRAP agents is a modern form of
trepanation, in which EBM cubes are inserted in the heads of medical
students (fig 2).







           Fig 2.   Skulls of medical students showing circular incisions of
trepanation used to insert EBM cubes








      EBM liturgy and sacraments

      The many forms of liturgy and sacrament that we have discovered
include:

        a.. EBM workshops, where the catechisms of EBM are chanted and
novices are taught the tenets of EBM
        b.. An annual pilgrimage to the Cochrane Colloquium, during which
EBM devotees go without sleep for four days, speak in tongues, and
participate in ritual ceremonies
        c.. A bizarre ritual in which structured abstracts are placed in the
gaping mouths of EBM devotees
        d.. The bestowment of holy orders upon those who go on to become
Tutors, Convenors, and Coordinators
        e.. Anointment of the sick with evidence at the bedside (fig 3)
        f.. A pilgrimage by truly devoted adherents to the religion, who
travel thousands of miles to be initiated using total immersion in Coote's
Paradise, at the western extreme of Lake Ontario
        g.. A finger that is believed to be a holy relic. Adherents are
divided as to the origin of the finger. One faction believes it came from
Gordon Guyatt, and another believes that it came from Drummond Rennie.








           Fig 3.   An EBM priest anointing a patient with evidence at the
bedside









       Proselytisation and excommunication

EBM shares with many other religions an aggressive proselytisation. New
members are recruited to the religion through workshops, colloquiums,
religious tracts, and other publications. Although EBM does not yet have its
own television channels, the internet is gradually being taken over by EBM
sites. A recent Google search (10 December 2002) revealed 1 240 000 EBM
sites.

Like other religions, EBM is quick to excommunicate those who do not adhere
to its tenets or who challenge the authority of the chief druids. Because of
the fear of losing its following to the drug industry, EBMers who take jobs
in industry are excommunicated. They may also be banished to live with
unbelievers and those who adhere to other religious creeds in New Haven or
at the New England Journal of Medicine, which are being transformed into
modern day EBM Lubyankas. Other punishable offences include failure to
publish the results of a trial and failure to report the results of a new
trial in the context of an up to date systematic review.



       The priesthood and EBM signs and symbols

We are able to publish a photo of three EBM druids dressed in their
vestments (fig 4). Note the socks, the shirts, and the sign they are making
with their hands. EBMers are easily recognised by their white socks. The
shirts seen in the photograph are worn at all times and never washed, but
are normally hidden underneath other clothing. The secret sign they are
making with their hands is used to identify themselves to each other, the
three fingers forming an "E" for evidence. EBMers are known to provide
mutual assistance and promotion within their secret order, sometimes using a
specific EBM vocabulary, including words such as "trohoc," and passwords
such as "allocation concealment" and "RCT," the last of which is used as a
title of reverence in place of the ineffable (randomised controlled trial).







           Fig 4.   Three EBM druids dressed in their vestments





Governments around the world are rejoicing in the growth of the EBM religion
because it makes it easier to withhold or withdraw support from all forms of
care for which there is deemed to be insufficient evidence. Meanwhile, the
drug industry is secretly assembling a massive fighting fund to protect
endangered drugs from the inroads being made by EBM. As a consequence of the
unbridled success of EBM, it is anticipated that nearly all surgical units,
public health departments, and paediatricians will be forced to close shop
because of a lack of randomised evidence supporting their activities.


            Factions and a glimmer of hope for the future

As in most other religions, factions are beginning to emerge within EBM, and
CRAP sees a glimmer of hope in these developments. EBM currently comprises
four major denominations:


      Dire consequences of EBM

      In addition to uncovering EBM religious tracts we have discovered top
secret plans that confirm and go beyond our deepest fears about EBM's
intentions to take over the world:

        a.. The BMJ, already in the thrall of EBMers, will take over all
other medical journals, using a combination of spamming and viruses to
attack their websites
        b.. The National Health Service will become the National Evidence
Service, with 80% of the time of all employees devoted to generating,
meta-analysing, and critically appraising evidence
        c.. An upper limit will be placed on the IQ of all students admitted
to medical school
        d.. Drug companies will be required by law to reveal all of their
evidence. As a result of this it is expected that by the year 2020 the last
of the 10 drug firms still in existence, following multiple mergers, will
close its doors due to the loss of the right to hold proprietary secrets
        e.. NICE (the National Institute for Clinical Effectiveness) will
take its gloves off and change its name to NASTY (National Academy of
Stingy, Therapoclastic, Nihilistic Yobs)
        f.. The Nobel Prize for medicine will be subverted. In the future it
will be awarded to large collaborative endeavours, rather than to
individuals. It will be given solely for methodological research into the
intricacies of randomised trials and systematic reviews
        g.. In future among doctors, only EBMers will be awarded
knighthoods, at one of three levels (Level 1, Level 2, and Level 3).


  a.. Cochranitesmembers of a worldwide order that has Archie Cochrane as
its patron saint. They worship systematic reviews
  b.. Meta-anophilesa heretical spin off of the Cochranites, who believe in
combining the results of all the randomised controlled trials in the
universe. Their current estimate of the ultimate summary statistic is 42
(95% confidence intervals 41.9999 to 42.0001)
  c.. PharmacoidsEBMers who work for the drug industry, sometimes secretly
funded. This faction was started by industry, which initially believed that
EBM would ensure continuation of their obscenely high profit margins,
because most randomised evidence concerns drugs. Many in industry now regret
this initiative due to the aggressiveness of the Cochranites and the
Meta-anophiles, who now demand that industry divulges all of its secret
evidence, instead of publishing only the evidence that favours its products
  d.. Simplefolkmembers of a much smaller order that worships large, simple
randomised controlled trials. Adherents want to make large simple trials
mandatory for all treatments, restrict the number of outcome measures to a
maximum of two, and allow only priests with a license to do subgroup
analyses.
In the end, EBM may destroy itself, just as many other religions seem to be
doing. However, CRAP will not sit by idly. We have plans to take EBM to
court in The Hague for crimes against humanity. Our case is based on
challenging EBMers to provide proof, based on a mega-RCT or a meta-analysis
of RCTs, that EBM does more good than harm. Where is the evidence?! It is
time for unbelievers and those of other faiths to get tough and put a stop
to the veneration of research evidence about the effects of health care. We
must protect our unalienable right to exercise clinical autonomy, so that we
can continue to do what we damn well please.

      Acknowledgments

Contributors: All authors contributed equally and all will act as
guarantors.

      Footnotes

Funding: None.

Competing interests: Lots (see bmj.com).



Cheers,

 Anna.


Anna Lee
Principal,
Work Ready Industrial Athlete Centre

Write to me at: [log in to unmask]

Visit me at: www.workready.com.au

Snail mail:
Suite 3, 82 Enmore Road,
Newtown  NSW  Australia 2042
Australia

Phone: (612) 95197436
Fax:  (612) 95197439
Mob: 0412 33 43 98

----- Original Message -----
From: "Patrick Zerr" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, February 06, 2003 3:57 AM
Subject: Re: evidence based practice


> I would have to agree.
>
> To think that PT treatments, especially manual techniques, are similar to
> prescribing x number of mg of penicillin is not the same type of RCT.
>
> There should be more focus on how we identify the differences in treatment
> and patient activity.  Because what we do is so dependent on what the
> patient does after they leave the clinic it's not accurate to say that the
> treatment has or has not been effective without knowing all the details.
> Until we can control for those details it will be difficult at best to
> examine the effectiveness of our treatments.
>
> Patrick Zerr
> www.apluspt.com
> The easiest way to prepare for the National PT Exam!
> www.summitpt.com
> Summit Physical Therapy; Tempe, Arizona
> ----- Original Message -----
> From: "Regis Turocy" <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Wednesday, February 05, 2003 7:37 AM
> Subject: Re: evidence based practice
>
>
> > Colleagues,
> >
> >   Who decreed that evidence based practice will save the profession. I
> > personnally belief, that if EBP is the only criteria we are going to
"hang
> > our hat on" it will be the DEATH of our profession. There are too many
> > unquantifiable factors involved in our various therapeutic approaches
and
> > the therapist-patient relationship. To use one approach (EBP) as our
only
> > criteria is extremely short sighted. I think it is just one of the many
> > factors that should be included in the equation. As you can probably
> > summarize, I am not that anxious to "jump on" the EBP bandwagon. I would
> > rather look at the millions of Americans who are "flocking" to
alternative
> > care clinics, who are getting better, after failing to do so with
> > traditional medicine and physical therapy(in spite of EBP) and ask WHY?
I,
> > like many of you, have a long clinical history and cannot ignore all
those
> > other factors that have resulted in a very successful therapeutic
outcome.
> >  From my perspective it is time we take the "empirical blinders " off.
> Just
> > a thought!!
> >
> > Rege
> >
> >
> > At 10:42 AM 2/5/2003 +0200, you wrote:
> > >I think Frank Conijn has made an important suggestion in his message of
3
> > >February. Namely: 'We have to work on saving our profession. But we can
> only
> > >do that with <valid!>, in the absence of validat<ed> arguments'.
> > >
> > >It is clear that such arguments can only be obtained via due research.
> > >However it is my personal impression that current PT researches
worldwide
> > >are mostly isolated and poorly coordinated (if coordinated at all). As
> far
> > >as I know, PT investigations have mainly been carried out at medical
> > >universities which may have their own local/specific interests, biases,
> and
> > >priorities, which not always take into account the higher goals of our
> > >profession. In addition, it seems that the teaching activity of
> university
> > >researchers has taken too much their time.
> > >
> > >In my opinion, we could consider an establishment of a global PT
research
> > >network dedicated exclusively to searching for those arguments Frank
> > >mentioned. Small informal groups of researchers or even separate
> individuals
> > >(e.g. supported with appropriate grants) could also be included into
such
> a
> > >network. Of course, it would hugely be welcome to coordinate these
> > >researchers' investigations conducted in various countries (i.e.
> conducted
> > >using a multi-central design). I think a possible bureaucratic manner
of
> > >such coordination will be minimized if we'll find several respectable
PT
> > >researchers worldwide who will rather be more interested in scientific
> > >soundness of our profession than in their remunerations appropriate. I
do
> > >not know whether the World Confederation for Physical Therapy has its
> > >Research Department. If yes, then we surely could use their experience
> and
> > >potentialities. If no, then we could use their successful experience as
> to
> > >effective organizing the PT practice and adapt it, to some extent, to
> > >coordination of our research efforts worldwide.
> > >
> > >Money? For the moment, I do not know from where. I am very far from
> > >answering this question. Especially when sitting in this
'restructuring'
> > >country. Maybe PT equipment companies... Maybe grant-giving
organizations
> > >(why not The Wellcome Trust, the most serious and powerful biomedical
> > >sponsor
> > >over the globe?).. Maybe appropriate State Departments charged with
> > >improving the quality of health care... Maybe all the listed in
> > >conjunction...
> > >I hope somebody from my colleagues abroad will be more productive in
> > >economic assessing such a project and advising relevant sources of
> funding
> > >worldwide. Let's think together. And create, anyhow, something like an
> > >'International Confederation for Physical Therapy Researchers'. Or
'World
> > >Physical Therapy Research Institute' (even virtual, not formal).
> > >
> > >In order to the validity of future results obtained by researchers of
> such a
> > >network cannot then be called in question by empowered persons and
other
> > >people, we should accordingly select those researchers taking into
> account
> > >their scientific degrees, professional honours, etc, which have
currently
> > >been recognized in most countries.
> > >
> > >I am confident of extreme necessity of urgent enhancing the level of
> today's
> > >PT research, and launching high-quality investigations into the
> mechanisms
> > >of influence of main PT agents and interventions. On the other hand, I
am
> > >sure that only sincerely devoted to Physical Therapy researchers from
> > >various countries whose efforts have delicately been coordinated by
their
> > >senior colleagues - informal consultants/coordinators - are able to
> provide
> > >us with the arguments Frank mentioned.
> > >
> > >What do you think about, dear colleagues?
> > >
> > >Stanislav Korobov, PhD
> > >PO Box 7, Odessa, 65089, UKRAINE
> > >
> > >[log in to unmask]
> > >[log in to unmask]
> >
>