Hi!
Does anybody know of somebody who has tried to assess an effect EBM (whatever
the definition of EBM), or plans to do such a study?
EBM adherents: Show your weight!
As for myself, EBM is like one of the famous saga's by the Dane H.C. Andersen
(printed more than a hundred years ago.
I will do my best to put down my own and others' contemplated reflexions on
this important topic.
I am serious!
//Bengt
>----Ursprungligt meddelande----
>Frċn: [log in to unmask]
>Datum: 2013-10-25 06:01
>Till: <[log in to unmask]>
>Ärende: Re: Criticisms of EBM
>
>Hi Anoop,
>
>I have seen this all before and first of all it is an unbalanced picture of
>what EBM is and does and I think deliberately so. Epidemiology is not true
>or false it is one system used for solving problems and evidence based
>medicine requires finding the best available evidence for your patient. EBM
>is bigger than epidemiology and does not depend exclusively on this field
>even though it is important. This movie gives no place for Equator
>guidelines, GRADE or even mixed methods research, it is just throwing rocks.
>We all know and people on this board have co-written papers on how in a very
>short span a large proportion of medical practice becomes obsolete as
>greater knowledge replaces outdated treatment and diagnosis. To lump EBM
>with insurance companies, opinion leaders and by implication pharma is a
>very inaccurate stretch of literary license.
>
> I find this rhetoric is high on justifying someone doing their own thing
>and calling it 'practice or art of medicine' rather than putting
>innovations and new research questions through the paces to find out if they
>are indeed safe and effective. People are deceived because they are wowed
>by statistics and percentages because math is not their friend. Notice there
>is no discussion of NNT NNH RR or even background of the intervention with
>the appropriate values. I would learn more reading the National Inquirer or
>the Daily Mail and at least then they would have coupons or some other
>little return for giving them my attention. I did a little article on EBM
>here http://www.ithinkwell.org/what-is-real-ebm/
>
>People die because of the sloppy practice of medicine and inaccurate maths
>along with trial results unregistered and unreported. This is also a form
>of sedition because it turns the common people against regulators like the
>FDA who are there to protect them and the people have no way of knowing what
>medicine is like in the countries where it is unregulated. Hint, people die
>and lose function because the lessons of ethics, research and epidemiology
>go unheeded. Watched it happen consistentlythat is why I ended up taking
>evidence based health care. The carnage and collateral damage from bad
>medicine does not bring people freedom it delivers death and deception.
>
>Best,
>Amy
>
>From: Anoop B <[log in to unmask]>
>Reply-To: Anoop B <[log in to unmask]>
>Date: Thursday, October 24, 2013 10:51 PM
>To: <[log in to unmask]>
>Subject: Re: Criticisms of EBM
>
>Here are some more of his comments:
>
>A short translated summary on the movie of Yvo Smulders
>Conclusions:
>- Epidemiological evidence is over appreciated
>- there are other, equally important sources of evidence than
>epidemiological evidence
>
>This is leading to a overkwalification of : ³thereıs no evidence for that
>(diagnostic tool / therapy / etc) ² This overkwalification of ³unfounded² is
>done by collegues, medical opinion leaders, government, insurance companies,
>etc.
>Epidemical evidence shouldnıt be the norm, because:
>- It is in many cases unavailable / not-existing
>- Often ³false²
>- Only occasionally external valid to the patient
>- It isnıt the critical factor in ³good healthcare².
>Only of 36% of the major / usual therapeutic interventions is benificial or
>likely tob e benificial.
>8% is a trade off, between benefits and harms, 6% unlikely to be benificial,
>and 4% is likely to be ineffective or harmfull. 46% there is no conclusive
>evidence. This is just about interventions, not prognostics, diagnostics,
>etc. etc.
>Cardiology guidelines, total guideline only has 11% level a recommendation,
>and of the class a recommandations only just under 20% level A evidence
>based. Weıll probably never close the gap.
>A lot of bias is present in epidemiological evidence.
>There is methodological evidence.
>example SSRIıs: Sponsored studies show many benefits, non-sponsored is about
>50-50, a lot of negative studies werenıt published.
>If you take all estimated bias in account you might do an educated guess on
>how true epidemiological evidence is (this is different from p-values): huge
>RCTıs and metareviews of large RCTıs 85% true; all others are below 50% true
>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 donıt 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 ³culture² (literally: ³soft
>variables²)
>On accountability: Only 4% of the medical mistakes are duet o shortcommings
>in knowledge. Rest is clinical reasoning, lack of commitment, lack on
>communication.
>
>
>
>On Thu, Oct 24, 2013 at 10:43 PM, Anoop B <[log in to unmask]> wrote:
>> Thanks Andy and David for your thoughts!
>>
>> Alex, also how delayed the research gets accepted and practiced. The
>> corticosteroid administration for premature babies is a good example I
feel.
>> The systematic review came out in 1981, but it was only routinely
practiced
>> after the NIH consensus statement in 1994! So we had the knowledge, but
didn't
>> translate into practice for reasons you cited. And thanks for the link.
How
>> people make decisions and learn is very fascinating and goes to the root
of
>> the problem, I feel.
>>
>> And I can understand all his criticisms. But I do hope he is not
suggesting
>> hence let's throw out EBM. My point is we can have all the criticisms, but
is
>> there a better alternative? No.
>>
>>
>> On Thu, Oct 24, 2013 at 9:18 AM, David Braunholtz <[log in to unmask]
com>
>> wrote:
>>> I don't speak Dutch either, and have no idea where the numbers come from
or
>>> if they are reasonable. However (as Yvo may very well have pointed out
>>> somewhere in his talk, before the clip) the evidence in EBM should not be
>>> thought of as just RCTs (or lesser comparisons) of therapies. If that is
what
>>> he means when referring to 'epidemiological evidence', he may have an
point:
>>> ie HSR (health services research) may be more important. HSR is
essentially
>>> about behaviours and systems, a much more difficult area to gather
'evidence'
>>> which will help design good interventions, as behaviours are complicated,
and
>>> (in my opinion) useful HSR evidence really is about reaching a good
>>> understanding of 'what is going on & why' (ie developing and testing
theory).
>>> NB this is in contrast to testing effectiveness of a drug in a patient
group,
>>> no knowledge of mode of action required !
>>>
>>> So Yvo would presumably support research and gathering of evidence (ie
>>> understanding) on how to improve clinical reasoning, commitment,
>>> communication, and other 'soft' variables ?
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>> On Thursday, 24 October 2013, 13:35, Anoop Balachandran
>>> <[log in to unmask]> wrote:
>>>
>>>
>>> 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 donıt 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 ³culture² (literally: ³soft
>>> variables²)
>>> 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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