In response to Benjamin Djulbegovic's request for comments I can add the
following:
My own experience in the evidence-based clinical improvement movement
started with reading David Eddy's essays in JAMA in 1990 dealing with
practice policies and his manual describing the "explicit" approach for
designing evidence-based clinical guidelines and other practice
policies. At that time I directed a CME office at Group Health in
Seattle. Because of David Eddy's brilliant I was able (with much help
from my colleagues) to create a clinical improvement department
utilizing the concepts, methods and tools outlined by Eddy. I believe
our department made significant, positive impacts on Group Health's
culture, leadership, work processes and outcomes. We developed and
implemented more than 35 evidence-based guidelines, pathways and other
and clinical improvements. David Eddy's essays, manuals and support was
critically important to our evolution and success with the
evidence-based process. Without concepts such as the "balance sheet"
and the "explicit" approach we would have had great difficulty.
-- Michael Stuart MD
President, Delfini Group,
Clinical Asst Professor, UW School of Medicine
6831 31st Ave N.E.
Seattle, Washington 98115
206-854-3680 Mobile Phone
206-522-4279 Home Office
[log in to unmask]
www.delfini.org
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Djulbegovic,
Benjamin
Sent: Saturday, February 12, 2005 8:27 PM
To: [log in to unmask]
Subject: Re: Innacurate EBM-labeled prediction dangers - Sackett said
indeed, it would be good if some of the folks who were at forefront of
the EBM movement join the debate and provide some further historical
account how EBM field has evolved. In the article, Eddy states that he
is the first to use the term "evidence-based (guidelines)" (1990), and
that term EBM was first used by Gordon Guyatt in 1991. My own account of
history of EBM has revolved around 3 development: 1. practice guidelines
and need to standardize practice (USA) 2. critical appraisal (Canada) 3.
systematic reviews (UK-Cochrane Collaboration)
For time being, these developments have been more or less independent
and only recently we have seen attempts to integrate them under single
EBM umbrella. The process is far from being finished, and to the large
extent because all of the developments mentioned above tackle only
superficially the activity which ultimately matters: decision-making
under uncertainty. For some reason, we have been very slow in adoption
of the methods for integration of evidence in decision-making (e.g.
decision analysis etc). I would be interested in hearing yours and
others' thought on these developments which goal ultimately has been to
introduce scientific rigour in the practice of medicine. ben
-----Original Message-----
From: Evidence based health (EBH) on behalf of Poses, Roy
Sent: Sat 2/12/2005 6:31 PM
To: [log in to unmask]
Subject: Re: Innacurate EBM-labeled prediction dangers - Sackett said
I do not intend to mean any disrespect, and have no doubt that Eddy was
talking and writing about these issues.
I am also answering this off the top of my head from home, and don't
have any source material handy, and doing medical history off the top of
one's head is hazardous, but,...
It seemed to me there were an awful lot of people also talking about
these issues, and some earlier than the 1980's.
First of all, although the term evidence-based medicine (or health care)
comes from the early 1990's, EBM or EBHC seems to me to be clearly a
successor of the clinical epidemiology movement, which I believe dates
from the 1970's, or earlier, and was put together by people from such
places as McMaster, Oxford, University of Pennsylvania, University of
North Carolina, and others. There was also sort of an alternative
clinical epidemiology movement championed by Feinstein from Yale. I was
taught clinical epidemiology at Penn, with emphasis on how to review
articles that describe clinical research and apply the results to
patient care, as a fellow starting in 1981. I was hoping some veterans
of these times were on this mailing list and could enlighten us further.
But lot's of people were talking about the quality of evidence by 1981
(and when I get to my office, I'm sure I can find some articles from
that time to document this.)
Furthermore, having gone to my first Society for Medical Decision Making
meeting also in 1981, I can also recall that lots of people were talking
about uncertainty, balancing benefits and harms, and patients' values at
that point, and that this movement also I believe started in the 1970s,
if not before. I can recall that David Eddy had some role in this
arena, but he had lots of company.
I have no problem with Eddy citing his own work. We all do that. But
in a keynote article on EBM in a journal that does not feature a lot of
EBM, I was hoping for a bit more balance.
Roy M. Poses MD
Center for Primary Care and Prevention
111 Brewster St.
Pawtucket
RI 02860
401 729-3400
fax 401 729-2494
email: [log in to unmask]
From: Djulbegovic, Benjamin
Sent: Sat 2/12/2005 4:16 PM
To: Roy Poses; [log in to unmask]
Subject: RE: Re: Innacurate EBM-labeled prediction dangers - Sackett
said
Roy, perhaps Eddy is a bit exaggerating but he indeed was of one the
first to talk about the quality of evidence, the role of uncertainty,
need for balance sheets (already in 1980s)- well before the term
evidence-based medicine was coined (1992, I think). Although he may be
overinterpreting Wennberg's data, I tend to think that he is basically
right- if medicine is science why there is so much variation in practice
between different countries, hospitals or physicians (as opposed to,
say, physics)? This question holds even when co-morbidities, patient
preferences etc are taken into account. ben
Benjamin Djulbegovic, MD,PhD
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