I think we should not be so quick to dismiss the criticism about the value of EBM that the recent e-mail raised. After teaching various courses on EBM (since 1997) and the attempts to integrate it in my own practice, I am not so sure how FEASIBLE is to teach EBM at bedside. Medicine is primary problem-solving and decision-making exercise. While we have all argued over the years that understanding the nature and quality of evidence etc is a key to practice of medicine, the original EBM paradigm (ask-search-appraise-decide) is simply very difficult to apply in practice. The primary reason, of course, is time-constraint. When my team has 20-25 of acutely ill patients on the ward and admit and discharge every day 3-7 patients, it is impossible to approach decision-making and problem-solving in EBM structured way. So, in practice, instead of serving as a facilitator, I end up spoon-feeding that necessary knowledge, which students, residents, fellows are supposed to discover on their own. When I don't know the answer, then we call consultants to help us with our questions. We simply don't have time to go through EBM process (despite the fact that I work in high-tech surroundings with computers at every corner, linked to any database you can think of...of course, we have journal clubs, teaching conferences, educational objectives, assignments and all that...we even do decision models, meta-analyses, understand the differences between normative vs. descriptive vs. prescriptive decision making etc). However, at the end of the day, it is CONTENT (i.e. content-specific expertise) that wins the day and not the process, or method-oriented approach which EBM paradigm promised. That is, the consultants (from the various disciplines who may or may not be of EBM kind) are the one whose advice you will follow (99% of time) regardless if that advice is EBM formulated or not. Several years ago I have been dreaming (and still do) that we will be able to identify all high-quality evidence (in my field, hematology and oncology), which we will then pre-processed and have at finger-tips at the bedside. Other folks have done the same in other areas of medicine. While I am still hoping that "thrill is not gone", EBM (and related initiatives including decision-analysis) has to face the key aspect of clinical medicine: LIMITED TIME FRAME FOR DECISION-MAKING UNDER CIRCUMSTANCES OF UNCERTAINTY.
I am hopeful that this e-mail, which I wanted to send for some time, but did not have time, will help stimulate some constructive debate.
Benjamin Djulbegovic, MD,PhD
Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute
at the University of South Florida
Department of Interdisciplinary Oncology
SRB #4, Floor 4, Rm #24031 (Rm# West 31)
12902 Magnolia Drive
Tampa, FL 33612
Editor: Cancer Treatment Reviews (Evidence-based Oncology Section)
http://www.harcourt-international.com/journals/ctrv/
e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/
phone:(813)979-7202
fax:(813)979-3071
-----Original Message-----
From: badri badrinath [mailto:[log in to unmask]]
Sent: Friday, September 05, 2003 8:57 AM
To: [log in to unmask]
Subject: Evidence based teaching
Dear Andrew,
Greetings from sunny Southend on the English coast.
You wondered "why teaching does not seem to have picked up on EBP"
There are some initiatives in this direction. Here are a few examples.
http://www.bemecollaboration.org/
Some of the topic reviews look very interesting.
http://www.bemecollaboration.org/topics.htm
http://education.ntu.ac.uk/research/ebt/ Evidence based teaching in primary
school.
http://nursing.jbpub.com/catalog/0763709379/ A text on Evidence based
teaching in the area of nursing.
Cheers & regards and have a wonderful weekend.
Badri
Dr.P.Badrinath M.D.,B.S.,M.Phil(Epid).,PhD(Cantab).,MPH., MFPHMI
Specialist Registrar in Public Health Medicine,
Southend PCT, Harcourt House,
Harcourt Avenue, Southend-on-Sea,
Essex SS2 6HE, UK
http://myprofile.cos.com/badrishanthi
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