JISCMail - EVIDENCE-BASED-HEALTH Archives

Hi Ash,

I will try to get the ball rolling but have no doubt my analysis will be shallow, inaccurate and downright post-positivist.

I have read this before and will start by saying there is something of value here - some of the criticism are valid and some part of the descriptions of the EBM movement are discomfiting to dwell upon. We should all strive to learn something from this kind of appraisal. There IS some degree of cultural hegemony in the way we go about our work, but it is not clear the authors have a response to the proposition that there may not be a better way. They dance around the alternatives and both neatly avoid and denigrate the concept that health outcomes are measureable and demonstrably 'good' or 'bad' in many cases.

Then there are passages like this:

"Thus, implicit in deconstruction is a suspicion of the essentialist and hierarchical nature of institutional knowledge. In a deconstructive vein, we must ask not only, ‘What constitutes evidence?’ but also, what is the ‘regime of truth’ (Kuhn would call this a ‘paradigm’ and Foucault an ‘épistèmé’) that dictates when or how one piece of evidence shall count as evidence, while another is denigrated or excluded altogether? In other words, what makes one piece of evidence so ‘self-evidently’ meaningful for us at this precise historical moment, while another appears so ‘self-evidently’ meaningless or nonsensical?"

Such passages are difficult to grasp without multiple readings (at least for me), but the authors seem to dodge the answer that what constitutes evidence is what works - at least until we find more evidence that something works even better. It makes for frustrating reading. The text is littered with 'straw man' arguments of low relevence - for example it will come as no news to the clinicians in this group that in the absence of high validity evidence (not invariably derived from RCTs), we must rely on evidence derived from other forms of inquiry. The authors here conflate 'RCTs represent the highest level of evidence' with 'all other evidence is to be dismissed as meaningless'.

There are also a lot of interesting references as to what constitutes truth. I am not entirely sure if the authors are of the Rudy Giuliana school (Truth isn't truth), but on many occasions I found myself substituting 'most likely to be true' in order to make the statement concerned relevant to my understanding.

I was surprised Derrida did not appear until page three, but there is a postmodernist tone to this article that is confirmed by the statement "..... we believe that a postmodernist critique of this prevailing mode of thinking is indispensable.". Postmodern discourse is strange and wondrous beast to me and I fear I have not absorbed all I might have yet. I find the whole quite a struggle to make sense of, and I am definitely to understand how EBM is implicated in the "the pathologisation of homosexuality within medical discourse." (is 'pathologisation' really a word?)

So, over to you guys. Am I hopelessly fascistic?

Mike