Dear all,
Thank you for some very interesting replies about evidence for
evidence. I particularly liked Scott Richardon's "whether and how".
I think the distinction between problem framing and problem
solving is applicable here. EBM is an excellent problem solving
method, but you have to frame the problem in a particular way before
it works. EBM's problem framing method is to get people "to ask
clinical questions you can answer". These questions are specific
(addressing eight central tasks - clinical findings, aetiology, diff
diagnosis etc) and have a particular structure (the four part
question). In that frame, the hierarchy of evidence suggested works
very well.
But what about clinical questions that don't easily fit this frame?
(such as "should I practice EBM?" or "should I be patient centred
in the consultation?" or "how should I balance detachment and
involvement with my patients?"). These aren't answerable in the same
sense, but all clinicians answer them by making choices that are
implicitly expressed in how they practice.
I personally don't need "good evidence" (in the evidence based
medicine sense of the term) to decide that EBM is worth practicing,
any more than I need it to decide that a "patient centred" approach
to the consultation is better than the alternatives. The evidence of
"compelling rationale", my own observations of other clinicians and
my own values about how to deal with people are quite enough.
I like EBM for the way in which it is explicit about strategies to
address those "clinical questions you can answer" that it allows.
Can we be similarly explicit about strategies to teach or learn about
other questions? I think it's mostly done by example, and
implicitly. I would be interested in how list members think doctors
should try to answer important questions of "how to practice" that
don't fit the EBM frame, or how such strategies could/should be
taught.
Bruce
PS I do get the sense that some people find this stuff a bit
tedious/navel gazing. Maybe this isn't an EBM issue. Sorry if
that's the case.
Bruce Guthrie,
MRC Training Fellow in Health Services Research,
Department of General Practice,
University of Edinburgh,
20 West Richmond Street,
Edinburgh EH8 9DX
Tel 0131 650 9237
e-mail [log in to unmask]
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