Hi Bill,
I'd agree that there is a tension between the population and the individual,
and I agree that the individual clinician's expertise/experience and the
patient's experience/values are key to good clinical decision-making -
that's one of the reasons I love EBP.
I like the Sackett et al definition that evidence-based practice is the
integration of the best available research evidence with clinical expertise
and the patient's values and preferences. Clinical and patient experience
aren't research evidence, but they are 2 of the 3 core components of
evidence-based practice. Integration of the 'population'-based research with
the individual clinician/patient context is the strength of EBP
What do you think?
Tari
Ref: Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB.
Evidence-Based Medicine: How to Practise and Teach EBM. Edinburgh: Churchill
Livingstone; 2000.
Tari Turner
Senior Project Officer
Centre for Clinical Effectiveness
Monash Institute of Health Services Research
Locked Bag 29,
Clayton Victoria 3168
Australia
Ph +61 3 9594 7568
Fx +61 3 9594 7554
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Bill Cayley, Jr
Sent: Wednesday, 16 August 2006 3:43 AM
To: [log in to unmask]
Subject: Re: The individual patient Vs the abstract EBM patient
I would agree w/ Rakesh that there is a tension
between the population-based nature of EBM, and the
individual nature of clinical medicine.
ONE part of the challenge in applying EBM to
individuals is simply being sure that the answer
derived from the literature is as precise as or TRULY
addresses the same question as what is applicable in
the patient's situation.
The other issue, though, has to do w/ the "Evidence"
(or call it information or knowledge or whatever)
derived from one person's experience. In the EBM
hierarchy of evidence, personal experience or anecdote
is considered the LOWEST level of evidence, yet it is
exactly the individual story of a given patient, or a
doctor's individual lived experience with a certain
treatment, or group of people, or environment, that is
key to knowing how to understand or apply a treatment
to a given situation.
How to balance (integrate?) population-based and
individual based evidence - THERE is a question!
Bill Cayley MD
--- Rakesh Biswas <[log in to unmask]> wrote:
> One of the major challenges in EBM for the
> practicing clinician is trying to
> match individual patient needs with the collective
> patient data that EBM
> generates.
>
>
>
> It is as if trying to compare a giant but abstract
> EBM individual that is
> statistically similar to our individual patient with
> the clinical query
> though not quite as human.
>
>
>
> In my work with medical undergraduates learning the
> ropes of clinical
> medicine, I often ask them to collect as many life
> events as possible in a
> patient so that it helps them to appreciate data
> like event rates in control
> and experimental groups from which they can further
> grasp terms like
> Absolute risk reduction etc. We often find that a
> person's pre-disease life
> events can be even more interesting and may
> sometimes even have a bearing on
> the disease events. (
>
http://www.medspan.info/component/option,com_smf/Itemid,84/board,24.0)
>
>
>
> The EBM literature neglects a lot of events it
> doesn't believe to be
> statistically significant as they are simply the
> norm or null by the very
> definition of hypothesis testing and perhaps here is
> an area that needs to
> be improved on. One needs to make the EBM individual
> (that is a projection
> of collective patient event data) resemble our human
> individual patient so
> that the ideal EBM individual that matches our query
> can be easily and
> quickly spotted from the dense jungle of evidence
> that has grown over the
> years. I guess this hints at rethinking our entire
> research methodology and
> modifying it to suit the needs of the individual
> patient but I am not sure
> if it is asking too much as I have tremendous faith
> on human adaptability
> and learning.
>
>
>
> Once the larger EBM prototype individual becomes
> friendlier and less
> menacing (as it is perhaps at present for many if
> not all practicing
> physicians) EBM shall claim a more stable perch in
> the evolutionary time
> scale of medicine.
>
>
>
>
>
>
> Rakesh Biswas MD
>
> Associate professor,
>
> Department of Medicine,
>
> Melaka-Manipal Medical College
>
> Jalan Batu Hampar, Bukit Baru,
>
> 75150 Melaka, Malaysia
>
> Phone: 60-6-2925851-extn 1151 (office) and 2001
> (residence)
>
> Fax: 60-6-2817977/60-6-2925852
>
> Mobile: 60-16-6434253
>
> Email: [log in to unmask]
>
http://www.manipal.edu/melaka/departments/departments.htm
>
Bill Cayley, Jr, MD MDiv [log in to unmask]
Augusta Family Medicine Home Address
207 W Lincoln 3433 McIvor St
Augusta, WI 54722 Eau Claire, WI 54701
Work: 715-286-2270 Home: 715-830-0932
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