Apologies for taking a while to post this reply to some of the points raised in this discussion.

 

Donna

- with regard to grading the evidence, and "clinician and patient... using their own judgement and experience" - I agree that this is vital to thoughtful professional practice, but for me the issue is how these diverse forms of knowledge are integrated. I don't want to promote the idea that everything that a professional does can be made totally explicit, but I do think that a better understanding of how professionals go about integrating different forms of evidence might enable us to a) make more considered decisions in complex situations and b) help prevent us 'falling back on' a straightforward hierarchy. What are your thoughts on this?

 

David

- I agree that "poor numeracy skills" are evident in many people. You may be interested to hear that here in the UK, the ESRC (Economic & Social Research Council) has specifically recognised this and is promoting 'quantitative literacy' within the social sciences (e.g. Master's research degrees contain equal training in quantitative and qualitative methods, PhD studentships that utilise quantitative methods in certain areas pay substantially more than standard studentships). I wonder if the ESRC's sister councils (e.g. the EPSRC - Engineering and Physical Sciences Research Council) will follow suit and similarly promote the development of an understanding of qualitative methods within their field?

 

Owen

- your call for practitioners to "deconstruct the evidence they are told to implement" is key - one of the prime drivers in EBM, if I remember correctly, was the importance of junior doctors being able to challenge the decisions of senior doctors on the basis of presenting better evidence- do you see any 'space' in EBM for using this as a basis for challenging "diktats from above"?

 

- I agree that much policy-making (health or otherwise) is driven by rhetoric, but I don't necessarily see this as a problem per se - in my view, the notion that science proceeds through the exchange of objective evidence between disinterested parties is untenable (it is the ideal, but it is not tenable). The use of persuasion (i.e. the artful utilisation of evidence) is part and parcel of both everyday life, the progression of science, and the activities of government and policy-makers. I can (try to!) expand on this line of thought if people are interested. And I should add that I can understand Owen's concern at the institutionalisation of the results of this process in social or medico-legal forms that effectively control the work of GPs and make sweeping assumptions about what values (across diverse ethnic and social groups) people should hold.

 

 

And, just to return to the topic that started this thread off (the Holmes et al 'fascism' paper). People may like to refer to the following paper (and also the debate in this and the previous issue of this journal):

 

Miles, A and Loughlin, M 2006 Continuing the evidence-based health care debate in 2006. The progress and price of EBM. Journal of Evaluation in Clinical Practice 12 (4) 385-398

 

These authors could hardly be said to be remotely 'postmodernist', yet I think that their critique of EBM is fundamentally the same as Holmes et al - they argue that EBM is not about evidence as such, rather it is the implementation of an ideology:

 

"We have arrived at a moment in intellectual history when criticism of dominant ideas can be dismissed, not because they have ever been demonstrated false, but because those with the power to shape and control debates (either because they own, or work for organizations that own, the media in which ideas are circulated, or in some cases they own the 'evidence' itself) regard these criticisms as simply 'not to our purpose'. We ought to be a lot more worried about this than many current commentators appear to be."

 

Thoughts?

 

Regards

 

Mark

 

Mark Pearson

School of Law and Social Science
University of Plymouth
20 Portland Villas 
Drake Circus
Plymouth 
Devon 
PL4 8AA


________________________________

From: Evidence based health (EBH) on behalf of Jim Walker
Sent: Wed 30/08/2006 19:03
To: [log in to unmask]
Subject: Re: Deconstructing the evidence-based discourse in health sciences)



Owen,
Very well said.
Thanks.
This would be worth turning into a published position paper.

Jim

James M. Walker, MD, FACP
Chief Medical Information Officer
Geisinger Health System

>>> Owen Dempsey <[log in to unmask]> 08/28/06 5:35 PM >>>
Hi Mark

you suggested I elaborate, and stated:

"..............whilst Owen states that his involvement with the education of primary care Doctors and Nurses has been notable for its production of practitioners who "just want to be told who to prescribe what to". ..........i.e. who are unable to think...... Yet Roy is concerned that EBM concepts have not affected the practice of medical education enough!"

Here are two examples of rhetoric being used to 'sell'  two products, the Polypill, and colonic cancer screening (in patients with an episode of rectal beleeding over the age of 45)

The Polypill, paper given a fanfare of trumpets by the BMJ
"About one person in three would benefit, and the Polypill would offer many people important extra years of active and useful life, with benefits evident over decades. The adverse effects, on the other hand, would mostly be apparent after a few weeks, in which case a variant of the pill could be substituted-for example, one without aspirin. ...........It would be acceptably safe and with widespread use would have a greater impact on the prevention of disease in the Western world than any other single intervention. "

Wald et alBMJ  2003;326:1419 (28 June), doi:10.1136/bmj.326.7404.1419



The cancer screening, from a single practice, in the BMJ.

"265 patients reported new rectal bleeding. Of these, 15 (5.7%, 95% confidence interval 3.2% to 9.2%) had colorectal cancer"

"We believe that most patients would accept that the level of risk we found-even at our lower confidence interval of 3.2%-is an adequate reason for investigation, and that current guidelines should be changed. "

http://bmj.com/cgi/doi/10.1136/bmj.38846.684850.2F

and the editorial:

"The study found that about one in 10 patients with new onset rectal bleeding had cancer. The authors say that general practitioners should investigate anyone aged 45 years and older who presents with rectal bleeding, with or without a change in bowel habit."

David Weller
BMJ 2006 333: 54-55




Now I'm not arguing against EBM at all, I'm just pointing out the biased rhetoric. The phrases including the word "acceptable" are not evidence based, they are value laden, and taken with the rest of the rhetoric are persuading  the medical profession to take action, the average GP in time will be expected (financially, morally and medico-legaly) to conform to this view and act accordingly.  How does the GP know what is acceptable to a given patient of mine in terms of risks? (and 60% of my practice population is Pakistani, with another set of values again) Is the GP really convinced that the benefits outweigh the harms? How does Wald know what is acceptable to society? How does he know what the implications are of implementing his strategy on a population's health beliefs, anxiety levels, expectations of life, health seeking behaviour. To what extent does such a high profile and powerful rhetoric reinforce the assumption that health service research should primarily be about longevity at all costs.  To what extent does it lead to a robotic workforce of doctors beavering away to achieve compliance with these diktats from above.

The facts of evidence should be enough, but this would require practitoners to be reasonably EBM literate, an important aspect of medical education. The aim of such education is not so much that more EBM diktats can be implemented and targets reached, but so that individual practitoners can use evidence in the context of their own professional practice, with a 'critical awareness' of the limited range of questions that are being asked and that these studies are able to answer, and of the socio-economic-political influences on the questions being asked, and an awareness of the dangers of EBM that are not mentioned by its advertisers (qv HRT, vioxx etc). 

Perhaps this will involve re-visiting concepts such as 'action-research' (see Winter, R (1989) Learning from experience: principles and practice in action-research), where individual practitioners are encouraged to deconstruct the evidence they are told to implement, be truly 'reflective' in the sense that they question the assumptions underlying the sort of statements seen above, and open their minds to alternative courses of action. 

I'm not anti screening per se but I am unconvinced that the evidence as presented is reliable enough to justify the rhetoric, I am very concerned that much of this evidence is becoming health policy by default.  I think the prominence given to this evidence, and the rhetoric is creating a 'regime of truth' that should be resisted from within the EBM movement. Medical education needs to continue to teach EBM principles but in addition we need more training in how not to implement EBM, and to do a lot more to encourage a critical thinking approach to the way EBM is being sold.  To ask : Who is making this (advert) product, How will they benefit, Who is it aimed at, What is its intention? How might it harm?

Owen

Owen Dempsey, GP

(vested interests; teach 'critical thinking' to medical students, GP)






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