Hi Piersante
Your question has provoked some interesting and useful responses.
I have recently been in a similar debate with people who think that the true path to knowledge is science-based medicine, which seems to me as pointless as the ancient debates over now obscure heresies. Who cares today about the differences between Anomoeanism and Semi-Arianism --- except, perhaps you :-)
I think that the basic problem is that there are two kinds of people: those who have a rules-based approach to thinking and those who have a heuristics-based approach.
People who have a rules-based approach to thinking will see EBM as a club or creed with fixed criteria for entry. They then project those *imagined* criteria onto anyone they think is an EBMer, and will regard them as heretics to be burned at the stake.
People who have a heuristics-based approach to thinking see that EBMers form a loose community of similar- (but not exactly like-) minded people. The important attribute that they share is a desire to find the best way to practice medicine, and a scepticism about all claims to have found anything better.
People who have a rules-based approach cannot have understood the history of EBM: it arose because evidence was not being optimally taken into account in clinical decisions; and, although the methods of EBM have improved enormously since its creation, there is no reason to think that it should not continue to evolve.
Michael
-----Original Message-----
From: Piersante Sestini [mailto:[log in to unmask]]
Sent: 19 August 2010 00:57
Subject: rules or heuristics?
Lately, I have been involved in a couple of debates with critics of EBM.
http://chestjournal.chestpubs.org/content/135/1/245.1.full
http://www.ncbi.nlm.nih.gov/pubmed/20367853
The charge of my opponents was, basically, that EBM consists largely in
the application of rigid rules (particularly about critical appraisal
and hierarchies of evidence).
My understanding, however, is that those are not rules, but heuristics
(rules of thumb) based of reasonable rational assumptions, while EBM
consists in the systematic and judicious integration of expertise and
data from clinical research to solve a patient's problem (which of
course includes preferences and values), not in following rules.
Their rebuttal, is that they are taught and practiced as rules, so that
to be an EBMer is commonly presented as rule-following.
I am confused, as I have always considered EBM more as critical thinking
and rule-breaking.
To consider checklists and hierarchies as prescriptive rules, rather
than working aids, seems to me to be at odds with the foundations of
EBM, since they are largely based on background information. It would
sound like to make a clinical choice based only on data from
pathophysiology.
So, my questions are:
How much is my view shared?
In your experience, how much of EBM curricula are dedicated to
understanding the principles behind the heuristics, rather than teaching
how to follow rules?
thanks,
Piersante Sestini
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