Hi Anoop
>> Some of his numbers, like "only 4% of the medical mistakes are due to shortcomings in knowledge" seem to be a bit far-fetched.
Well, I don’t know about the whole range of medical errors, but in a retrospective US audit, published in 2005, 100 cases of diagnostic errors were used to determine the significance of the roles that cognitive and system-related factors play in diagnostic errors. Diagnostic errors were rarely caused by inadequate knowledge (in only 4 cases, each concerning a rare condition, i.e. 4%. Seven cases involving inadequate skills involved misinterpretations of X-ray studies and electrocardiograms by non-experts). The most common reasons for misdiagnosis were system-related factors, cognitive-related factors or a combination of both.
See http://www.npc.nhs.uk/rapidreview/?p=4098 for a review.
To be a bit provocative, IMHO the greatest single fallacy that EBM-advocates can fall prey to is that propositional knowledge ('knowing that') is all that is required to ensure good care (appropriate resources aside e.g. actually being able to offer an expensive but evidence-based treatment) – that it will automatically translate into procedural knowledge ('knowing how and what to do') and that people will automatically do it. If that were the case, uptake of new evidence would not be an issue, and innovation would flow into practice like water through a pipe. But does that happen? I think not!
As Douglas Adams said, 'people are a problem'. Knowing the evidence is necessary but it is by no means sufficient. Adoption of evidence into practice depends ultimately on decisions to change made by individual people. Healthcare does not and cannot operate ‘like a well-oiled machine’. It is provided for individual people (and their carers) and by a number of teams of individual people. All these people have the freedom to act in different ways that are not totally predictable, and whose actions are interconnected and affect those of others. Personal mental models, relationships and interpersonal influences, as well as organisational matters, are therefore critical factors. All these factors interrelate and affect one another in complex and evolving ways which are not predictable and may be surprising. See http://www.npc.nhs.uk/merec/therap/other/merec_bulletin_vol22_no2.php, where colleagues and I develop this argument further and suggested some approaches in response.
Cheers
Andy
Andy Hutchinson
Medicines Education Technical Adviser
Medicines and Prescribing Centre
National Institute for Health and Care Excellence
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-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Anoop Balachandran
Sent: 24 October 2013 13:35
To: [log in to unmask]
Subject: Criticisms of EBM
Does anyone have any comments on Yvo Smoulders criticisms of the EBM approach.
http://www.youtube.com/watch?v=PRiSlU1ucqI
"
I don't understand Dutch so I couldn't find out where he got most of his numbers. Some of his numbers ,like "only 4% of the medical mistakes are due to shortcomings in knowledge" seem to be a bit far fetched.
Some if his commented translated by another person:
"Even if you consider epidemiological to be true, the best case scenario is that epidemiological evidence is external valid in 40% of the patients with a complaint, in the worse case scenario that is 0,001% Thus, all-and-all it is pretty weak:
1/3 is studied
1/2 is true
It is only external valid to 10% of your patients You probably don’t know more then 50% of all relevant evidence THUS 1/120 of your therapeutic actions are based on evidence!
If you compare hospitals who score high on quality care, vs. Hospitals who score low on quality of care, the critical factor does not appear to be EBM on epidemiological studies. The critical factor seems to be the fact that the better hospitals are known for their a good “culture” (literally: “soft variables”) On accountability: Only 4% of the medical mistakes are duet o shortcomings in knowledge. Rest is clinical reasoning, lack of commitment, lack on communication."
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