Michael, thanks for this great lecture. I actually listen to it with a couple of my residents today. I must say that Prof. Baum's lecture underscores the same point I am making: you can come up with 3 different recommendations if you adhere to patient's values vs. scientific evidence vs. physicians' expertise (which he called intuition)! For example, scientific evidence is clear that (if our goal is to prolong people's life), the patient presented in the lecture should receive a genetic test for BRCA mutation (followed by prophylactic mastectomy). This would mean that if the patient wanted to maximize her life expectancy, based on scientific evidence, she should not conceive. The patient did not want to have the test and chose have [a second] child instead. Doctors' expertise indicate that pregnancy will be detrimental to pregnancy and that treatment itself will likely be associated with toxic effects both for the baby and the patient. Doctor's best advice: abortion. The patient elected to deliver the baby (and get chemoRx and surgery).
More generally, this is a classic case of violation of the transitivity principle of rational decision-making, which states that if we prefer A>B and B>C, then we should also prefer A>C. As your example illustrated, advice based on best scientific evidence conflicted with advice based on physicians' expertise vs. what patient valued.

This is exactly reason that I suggest that definition of EBM should change. Of course, I am not saying that expertise and patients values are not important. On the contrary! All I am saying that according to the most popular definition of EBM "anything goes" as far are practice recommendations are concerned. And, as wrote in my previous e-mail, I think this is not good for EBM movement. Hence, we need a different definition of EBM.

Best
best

Ben Djulbegovic, MD
Professor of Medicine and Oncology



-----Original Message-----
From: Michael Power [mailto:[log in to unmask]]
Sent: Saturday, August 08, 2009 10:26 PM
To: Djulbegovic, Benjamin
Cc: [log in to unmask]
Subject: RE: Medical humanism and evidence-based practice may collide

Ben

You and I are talking about different issues. You are talking about integrating clinical experience with research evidence. I was talking about integrating values with clinical practice. I will comment on both issues, beginning with integrating clinical experience with research evidence.

Your example shows that there is a problem with integrating clinical experience in your sense, which is the obvious interpretation of the phrase with research evidence. I interpret the phrase to mean the evidence on a particular patient gathered from the history, examination, and special investigation; this evidence needs to be integrated with research evidence to make a sensible decision about the appropriate clinical management. This definition of EBP needs to be rewritten!

Although values always affect decisions, the EBP community has tended to avoid looking at how we integrate (or how we should integrate) patient-values with research evidence.  Sometimes it can be difficult to decide what the appropriate decision is. For example, when a pregnant woman has a life-threatening disease, and treatment of the disease would be dangerous to the fetus. (For a detailed example, see Professor Michael Baum's Samuel Gee memorial lecture at https://admin.emea.acrobat.com/_a45839050/p69282078/. Skip to slide 36 if you are in a hurry. If you are not in a hurry he has some interesting things to say about concepts of holism in orthodox medicine and alternative medicine.)

The literature on integrating values with EBP seems to have been largely written by Bil Fulford and his colleagues (I would appreciate pointers to other authors). The following link is to a paper that gives 10-principles of values-based practice and shows how values-based practice relates to evidence-based medicine.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16954004


Michael






________________________________________
From: Djulbegovic, Benjamin [[log in to unmask]]
Sent: 08 August 2009 21:14
Subject: Re: Medical humanism and evidence-based practice may collide

Michael, a couple of weeks ago or so, I commented that the "classic" definition of EBM ("the integration of best research evidence with clinical experience and patient values") is inadequate and should change (if the goal is to improve decision-making). A couple of people sent me their personal notes asking me to explain what exactly I meant by pointing to the impossibility of integration of descriptive aspects of decision-making (e.g. personal experience) with normative one (e.g. unbiased evidence) to derive prescription for optimal decision-making. I responded with a couple of examples illustrating how experience is so prone to error that we can never be sure that integration of particular experience with best evidence will in fact lead to optimal prescriptive course. For example, I have a colleague who once missed brain tumor in the patient complaining of headache. Ever since he has used this "experience" to justify ordering imagining studies in all of his new patients presenting with headache. As I was rounding this am, I saw tons of tests and treatments being ordered based on someone's "experience". In most of these cases, it would be difficult to argue that the decisions that were made (and are being made in thousands of other patients on daily basis) represent an optimal course of action (despite the fact the actions in all of these cases met classic definition of EBM). (I am not only talking about heuristic and biases that shape everyone's experience...)
So, I suggest again that we abandon the impossible dream and re-define EBM. (I personally favor David Eddy's definition of EBM as a "set of principles and methods to
ensure that, to the greatest extent possible, population-based policies and individual decisions are consistent with evidence of effectiveness and benefits").

ben

-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Michael Power
Sent: Friday, August 07, 2009 8:29 PM
To: [log in to unmask]
Subject: Re: Medical humanism and evidence-based practice may collide

Hi Carlos

Groopman and Hartzband use a definition of EBP that I am not familiar with. They say evidence-based practice "aims to put medicine on a firm scientific footing; experts evaluate the best available data and develop clinical guidelines designed to standardize procedures and therapies".

The second edition of How to practice and teach evidence-based medicine by David Sackett, Sharon Strauss, W Scott Richardson, William Rosenber, and R Brian Hayns defines EBM as "the integration of best research evidence with clinical experience and patient values". The book was published in 2000.

I suspect that the author's chose their narrow definition (thus creating a false dichotomy) so that they could make their article more dramatic, for example by using the image of medical humanism colliding with EBP. In fact EBP coalesced with medical humanism at least 9 years ago. If EBP is imperfectly practiced, this is evidence of a problem with the practice, not with EBP.

Michael




________________________________
From: Dr. Carlos Cuello [[log in to unmask]]
Sent: 07 August 2009 16:43
Subject: Medical humanism and evidence-based practice may collide


I would like to hear opinions on this

NEJM: Groopman, Hartzband: Medical humanism and evidence-based practice may collide.

http://bit.ly/4YWm3


--
Carlos A. Cuello-García, MD
Director, Centre for Evidence-Based Practice-Tecnologico de Monterrey
Cochrane-ITESM coordinator. Professor of Paediatrics and Clinical Research
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