Jacob and Kev,
I must confess that for me this top down approach remains quite
overwhelming and intimidating from a personal labor perspective especially
over the multiple topics that would be needed by a general Physician. I
have stayed silent on this until now because I felt perhaps it was my
personal concern and that I just needed more expertise. This is likely
still true but nevertheless Jacob raises important issues. If we want
those that practice to be active as well as passive contributors how are
we making that a reality?
There is the aspect where we want the best quality and I understand the
need for quality. That being said all the search quality in the world will
not fix some of the bias problems we face because they are not initiated
by the doctor trying to find the best intervention for the patient but are
triggered by industry data games. This is indirectly evident in multiple
Cochrane reviews as well where researchers unknowingly quote research
where data reporting has not been transparent. In my field I know this
because I can spot the players and know the latest work but in areas where
I most need clinical expertise quickly this is not the case.
There is the drawback that if all this is beyond the reach of those with a
day job due to time and expertise constraints there will be few
contributions from them, the learning will be passive and their voice, the
voice of those in the trenches will be lost. Are their ways we could
simplify the process and be more inclusive without compromising quality?
Are those in daily practice and our junior Drs just meant to be passive
consumers of Up 2 Date and other commercially prepared solutions. If this
is the case how does it differ from the old textbook days and how will
active interest in EBM and consumption be sustained and integrity
maintained over time if the users role is reduced to that of only a
passive consumer without input?
Best,
Amy
On 10/26/12 1:09 AM, "Jacob Puliyel" <[log in to unmask]> wrote:
>Dear Kev
>You write
>"The conclusion seems to be that at least most of the time,
>a less than comprehensive search will give us the same outcome
>as a comprehensive search. Unfortunately, there may be occasions that
>this is not so.
>The trouble is, we cannot tell when those occasions will occur."
>
>Please let me suggest that by letting perfect become the enemy of the
>good,
>we may be doing more harm than good to the cause of EBM.
>
>EBM began as a ³bottom-up² paradigm that taught residents to ask
>answerable
>and focused questions, search the literature in a transparent and
>reproducible way
>to find the best evidence and to critically appraise it in an explicit and
>structured manner, often using mathematical analyses to give a clear idea
>of the strength,
>statistical significance and possible clinical significance of the
>results.
>
>Unfortunately it is no longer an amateursı enterprise.
>Journals now insist on numerous boxes being ticked before they
>will even consider an review article for publication.
>Multiple data bases have to be explored, the references in the papers
>need to be hand-searched for new references,
>clinical trials registers and conference proceedings scrutinised
>and pharmaceutical companies and individual researchers must
>have been contacted for unpublished data and ongoing trials.
>
>Only organisations with very deep pockets can afford this anymore.
>Vested interests and jumped into the void.
>Now we have even Cochrane Meta analysis,
>written up by persons with direct conflicts of interests declared.
>
>Als-Nielsen and colleagues have shown that association
>with for profit organisations had little impact on treatment effect
>but the conclusions were more positive due to biased interpretation
>of trial results (Als-Nielsen et al 2003). Lundh and colleagues have
>shown that
>publication of industry-supported trials was associated with an increase
>in journal impact factors and revenue (Lundh et al 2010).
>Smith (2010), the former editor of the BMJ, has suggested that
>publishing the RCT sponsored by one drug company could
>yield a million dollars in the sales of reprints alone.
>
>We can counteract this form of biased interpretation only if allow
>less comprehensive searches done be independent
>researchers to challenge these 'comprehensive' reports.
>
>I must declare that most of this stuff I had researched for paper on EBM
>published elsewhere (Evidence Based Medicine: Making It Better)
>
>Jacob Puliyel MD MRCP M Phil
>Head of Pediatrics
>St Stephens Hospital
>Delhi
>
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