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Amy, All, I think you (appropriately) bring it back to the NEJM Perspectives article that started this thread (cases can and will, and sometimes should affect decisions). You also remind us that there is "the evidence" and how to best use it, and then.how it ends up getting used in practice. Just because someone uses RCT evidence incorrectly is not reason to not rely on RCTs for what we know they can tell us. It is further reason to teach how to practice EBM properly in my view (conscientious, explicit use of the current best...). Best Rich _____ From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Dr. Amy Price Sent: Sunday, July 10, 2011 8:42 PM To: [log in to unmask] Subject: Re: EBM Anecdote: Today's NEJM Dear All, The question that comes to my mind very interesting elephant and all is what are the long term (as in the over two years efficacy results) for this product in comparison with controls, those with existing CVR within the groups and mortality rates in general? I would rethink the hypothesis about the availability heuristic for decision one choices being stronger for case reports/clinical practice experience as I can't tell you the number of medical professionals that go by what their peers think according to the latest RCT or Meta analysis that they have likely never analysed but that a drug rep pointed out to them rather than by what is happening in front of them with their own patients. Decision making is important and both system one and system two are critical for efficiency and excellence. To me the key is to be aware of which system is in use and to know when to switch system camps as in know when to hold and when to fold. Some of this thinking is below conscious attention but there are ways to increase awareness and sharpen these skill . I find huge studies are not always good studies and that case reports/series can be very informative and bring light to nuanced areas a larger study has not controlled for. Or in the words of Ravi in another email "The art of medicine lies in individualizing the evidence to a single individual" Best regards, Amy Amy Price Http://empower2go.org Building Brain Potential From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Richard Saitz Sent: 10 July 2011 12:59 PM To: [log in to unmask] Subject: Re: EBM Anecdote: Today's NEJM More on the availability heuristic just published today. http://ebm.bmj.com/content/early/2011/07/07/ebm-2011-100073.extract?papetoc best, Rich Richard Saitz MD, MPH Professor of Medicine and Epidemiology Editor, Evidence-Based Medicine, British Medical Journal Group Boston University Schools of Medicine and Public Health Boston Medical Center _____ From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Kalliainen, Loree K Sent: Thursday, July 07, 2011 9:55 AM To: [log in to unmask] Subject: Re: EBM Anecdote: Today's NEJM Yet the isolated experience may engender a response which is disproportionate to the actual risk (vis a vis the anxiety about using epinephrine-containing local anesthesia in the fingers which has been debunked in the hand literature but still believed by non-hand physicians). Loree K. Kalliainen, MD, FACS St. Paul, MN, USA _____ From: Evidence based health (EBH) [[log in to unmask]] On Behalf Of Bill Cayley, Jr [[log in to unmask]] Sent: Thursday, July 07, 2011 7:49 AM To: [log in to unmask] Subject: Re: EBM Anecdote: Today's NEJM I think the most pithy part of the article is the phrase: "Informed adverse anecdote transforms scattered data into sound clinical judgment" To my way of thinking (OK, so we're starting w/ anecdote already!) evidence is simply "any observation" - the difference between anecdote and RCT and meta-analysis is simply the degree to which the evidence is ORGANIZED and SYSTEMATIZED. Still, it takes real-life, clinical experience to know where to look and have the perception of nuance to know how to organize the evidence. Bill Cayley, Jr, MD MDiv [log in to unmask] Work: Augusta Family Medicine 207 W Lincoln, Augusta, WI 54722 Tel: 715.286.2270 Pager: 715.838.7940 Home: 3604 Sharon Drive, Eau Claire, WI 54701 Tel: 715.830.0932 Mobile: 715.828.4636 A cheerful heart is good medicine... (Proverbs 17:22) From: Rakesh Biswas <[log in to unmask]> To: [log in to unmask] Sent: Wednesday, July 6, 2011 11:19 PM Subject: EBM Anecdote: Today's NEJM To quote from: http://healthpolicyandreform.nejm.org/?p=14876&query=TOC "The key is to use these flashes of physician anguish to illuminate the Level I evidence and identify the real risk factors for a bad outcome. I suspect the amygdala did not evolve to store odds ratios and heterogeneity P scores, but when an adverse event has prompted me to review the literature, I come away with a clearer understanding. There's nothing like a baby free-floating in the abdomen to drive home the lessons from a prospective study of risk factors for uterine rupture. 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