Dear Dr. Guthrie,
It is with some trepidation that I approach your very interesting message.
Accepting, though not very eloquently I admit, the challenge presented by
your questions, how about these:
> "should I practice EBM?"
In general medical practice in a large city, does evidence-based
practice [defined], compared to the traditional practice model [defined],
produce better patient outcomes [defined], save money, reduce mortality,
increase compliance . . . ?
>"should I be patient centred in the consultation?"
Would my population of patients [characterized] or this particular
patient [described] have better outcomes [defined] or be more satisfied
[defined] if a patient-centered approach [defined] were used than if a
traditional disease-centered approach [defined] were used?
>"how should I balance detachment and
>involvement with my patients?"
[The problem with this is the use of such fuzzy terminology, and if
well defined would probably end up looking like the previous question about
patient-centered practice.]
I'm quite certain others could devise much better ways of putting these,
but my point is that all the questions you put could be answered by
evidence, if the evidence were there.
>. . . all clinicians answer them by making choices that are
>implicitly expressed in how they practice.
The more I look at this, the less I understand it. Aren't you in
fact referring to the traditional model?
>I personally don't need "good evidence" (in the evidence based
>medicine sense of the term) to decide that EBM is worth practicing
Why not? It'd be great to have something besides intuition to
support our virtue.
> The evidence of "compelling rationale",
> my own observations of other clinicians and
>my own values about how to deal with people are quite enough.
Compelling rationale is a weak reed, as RCTs have repeatedly shown.
>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
First you have to show that there are important questions that
don't fit even with specific, well-defined terms. If you regard best
evidence as the fundamental concept, rather than "evidence-based medicine"
as defined at McMaster or Oxford, I think the problem you are worrying
about evaporates. Just about any question for which you may expect a
factual answer can be framed so as to allow a specific answer.
>PS I do get the sense that some people find this stuff a bit
>tedious/navel gazing. Maybe this isn't an EBM issue.
They are important questions which speak to one's approach to the
practice of medicine in the broad sense as well as to specific clinical
questions. There is no reason why scientific principles cannot be applied
in the former as well as to the latter case.
I believe strongly that we have an obligation to our patients, our
profession(s), and ourselves to make our practice as evidence-based as it
can be. So although I'm a bit uneasy about how this will be received, off
it goes!
Regards,
Sue Kaiser
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