I think one of the most significant issues that stands in the way of EBM is the powerful factor 'human nature'.
There is a significant amount of literature on how people make decisions (as mentioned in the previous e-mail). One of the clearest lessons is that in times of uncertainty people turn to their colleagues for advice - not abstracts things such as Medline, Cochrane etc. This point was beautifully illustrated in Gabbay's recent paper in the BMJ (http://bmj.bmjjournals.com/cgi/content/full/329/7473/1013).
Invariably anecdote (from a trusted source) takes precedent over evidence.
Best wishes
jon
Jon Brassey
NLH Q&A Service
www.clinicalanswers.nhs.uk
TRIP Database
www.tripdatabase.com
>
> From: Simon Hatcher <[log in to unmask]>
> Date: 2004/11/29 Mon AM 09:38:27 GMT
> To: [log in to unmask]
> Subject: Re: Epistemology and EBM
>
> Dear Ted
>
>
>
> One of the aspects that EBM seems to have missed is the whole
> database/evidence around how people make decisions. There is a vast amount
> of evidence on decision making in health care which isn't incorporated into
> current models of EBM. Much of which reflects the discussion in this thread
> to date. For example how precisely do you incorporate a patients values into
> decision making when you are having a conversation with them? How you frame
> a choice - in terms of benefits or harms - makes a big difference to what
> people decide.
>
>
>
> The second point, I would suggest, is that EBM applies to medicine in a
> professional sense. It doesn't seem to apply to informal health care
> decisions made outside a professional context - that is there are boundaries
> beyond which EBM doesn't apply. Not all health care decisions are made in a
> professional setting - some especially involving "informal" treatments such
> as going to bed to rest, drinking plenty of fluids, etc are essential
> preliminaries that happen before someone sees a health professional.
> Essentially these are not "technical matters". The negative consequences of
> these interventions are minor and they work in most cases - a situation
> which may well have applied to the herbal remedy suggested by the trainee at
> your workshop.
>
>
>
> Cheers
>
>
>
>
>
> Simon
>
>
>
> Dr. Simon Hatcher
>
> Senior Lecturer in Psychiatry
>
> University of Auckland
>
>
>
>
>
> -------Original Message-------
>
>
>
> From: Ted Harding
>
> Date: 11/27/04 04:56:48
>
> To: [log in to unmask]
>
> Subject: Re: Epistemology and EBM
>
>
>
> Hi Ronan,
>
>
>
> On 26-Nov-04 Ronán Conroy wrote:
>
> > Fascinating how a moral dimension immediately enters. People
>
> > ought to think, and to base their actions on the conclusions
>
> > of logical thinking. Why should this be so? Would anyone ever
>
> > fall in love, or play a Beethoven sonata again if this were so?
>
>
>
> Your point is good, but you are arguing somewhat outside the
>
> domain I had in mind.
>
>
>
> I'm not saying that people should base all their actions, or
>
> even attitudes, on the conclusions of logical thinking. I can
>
> grant that epistemology, etymologically and in the dictionary,
>
> means the study of "what we know and how we know it" -- or,
>
> more abstractly "the theory of knowledge", though it has itself
>
> to grapple with the meaning of "know" and "knowledge". (In so
>
> far as it remains descriptive, the latter can to some extent
>
> be avoided.)
>
>
>
> Action is a response to an urge or to a need, the consequence
>
> of a decision or of following a rational or irrational preference,
>
> or even "involuntary". This can be *influenced* by the conclusions
>
> of logical thinking, but in real life (as you exemplify) is
>
> often not *governed* by it. Even after falling in love (which
>
> can be involuntary) one may still agonise quite logically
>
> over whether one should allow oneself to pursue that state to
>
> its natural conclusions. A part of the "data" in this agony
>
> will be the powerful urge arising from the state, and one may
>
> yield to this despite powerful logical misgivings.
>
>
>
> I play Beethoven sonatas because I enjoy doing so, but would
>
> (without great agony) avoid doing so at 3 a.m. in the morning
>
> if it would be likely to wake the neighbours. My judgment on
>
> that likelihood would be, broadly speaking, evidence-based
>
> (either based on my knowledge of the behaviour of sound in
>
> the building where I live, or even on the outcome of a visit
>
> from the neighbour ... ).
>
>
>
> The situation I was addressing was one where, in that example,
>
> a young doctor had consciously, therefore potentially rationally,
>
> contemplated a problem described by her neighbour, and had
>
> deliberately proposed a course of action. In that case, one
>
> would expect that rationality was playing a substantial part.
>
> Unless of course that young doctor was somehow "in love" with
>
> herbal remedies ...
>
>
>
> A physician is in the position of an "authority" -- someone
>
> expected to be well informed about what's good to do, or at
>
> least be aware that they're not well informed, and reliable
>
> in their judgment.
>
>
>
> > [...]
>
> > The idea that human behaviour is shaped by the application
>
> > of logic to knowledge is a comfortable fib for which there
>
> > is no evidence. Learning logic does not make humans wiser or
>
> > act more compassionately. But a lobby of the medical profession
>
> > sometimes seems to believe that logic and rational behaviour
>
> > should be promoted with the vigour of a religion.
>
>
>
> I would not, any more than you, go along with the proposition
>
> that "logic and rational behaviour should be promoted with the
>
> vigour of a religion." It's entirely natural for behaviour to
>
> be irrational: indeed one may naturally act contrary to the
>
> dictates of logic, and I would not necessarily say that this
>
> was wrong.
>
>
>
> But to draw from this the conclusion that logic should generally
>
> not be taken into account would be to condone acting recklessly .
>
>
>
> In a context where there are aspects which (in principle) are
>
> based on logical principles, then one should, for the sake of
>
> one's own efficacy, examine if one can the logical aspects in
>
> order to evaluate them. But logic can only be guaranteed to give
>
> the right answer (if then) when it is based on all relevant
>
> available information. When based on incomplete (or, even worse,
>
> irrelevant) information, apparently "logical" conclusions can be
>
> false. When you are aware that the information is incomplete
>
> (and often it is simply not available) then it is good to be
>
> aware that one's beliefs about the situation are uncertain.
>
>
>
> To come back to the playing of Beethoven sonatas, there is
>
> a logic (mechanical and musical) to the execution of the
>
> performance. I wouldn't object to someone who had neither any
>
> mechanical technique nor yet good musical appreciation sitting
>
> down at a piano and laboriously and painfully trying to pick
>
> out the notes: if they're enjoying themselves that's OK, and the
>
> experience may lead on to learning the skills and appreciating
>
> the music better.
>
>
>
> Indeed, I would hope that this would lead them to the conclusion
>
> that they could usefully take lessons to improve their technique
>
> and understanding, for the sake of producing something that's
>
> closer to the performance thay have in their head. As anyone
>
> who's been through that will know, there's a very strong logical
>
> aspect to this process: you have to do a lot of working out, in
>
> your head, before it begins to become fluent.
>
>
>
> However, if someone who claimed to be a trained pianist played
>
> in a way which indicated that they didn't care about these
>
> things, then I think I'd be offended by it (even if it did
>
> sound better than the clumsy fumblings of the complete beginner).
>
>
>
> The point is that it's not only a question of pure musical
>
> experience: it's also, intricately, a technical matter.
>
>
>
> Likewise, I believe, for medicine in its scientific aspects.
>
>
>
> I'm not excluding "human-based medicine". A shrewd physician
>
> could in certain cases solve a problem by pure sympathy.
>
> But that's not going to cure a case of syphilis on its own
>
> (even if it helps the patient to maintain contact and stick
>
> to the treatment).
>
>
>
> When it comes to technical matters, there are right ways and
>
> wrong ways, and these are what are amenable, in principle, to
>
> rigorous examination and the application of logic.
>
>
>
> Best wishes to all,
>
> Ted.
>
>
>
>
>
> --------------------------------------------------------------------
>
> E-Mail: (Ted Harding) <[log in to unmask]>
>
> Fax-to-email: +44 (0)870 094 0861 [NB: New number!]
>
> Date: 26-Nov-04 Time: 15:49:29
>
> ------------------------------ XFMail ------------------------------
>
>
>
>
>
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