t's known that less than half of the things we do in a hospital are evidence-based

[SRW]

http://www.montereyherald.com/joycolangelo/ci_9939596?

Or so it is stated in this article by Joy Colangelo.


Some of her comments are:

Hippie dippie is the trade term for HPDP, or "Health Promotion, Disease Prevention." The goal is to make us all feel like time bombs with a half dozen risk factors found only by screenings. And yet the only screening that unequivocally reduces mortality is the Pap test.


Prostate screening shows evidence as well—evidence that we are not saving any lives by testing. More men will die with prostate cancer than of it and 90 percent will live 15 years without treatment. Aggressive cancer is incurable anyway, so it doesn't really help to find it earlier or later. Anyone have any comments on this? I think she is making some extremely dangerous statements.

It appears her source is http://www.cochrane.org/index.htm, anyone know about them?

TIA Steve

[fls]

I couldn't get the other link to work (don't know if it's just me).

http://www.montereyherald.com/columnists/opinion/ci_9939596

Well, it's true to form - misinformation and misrepresentation. Since most lay press (I realize she is an Occupational Therapist, but that doesn't give her special knowledge on the subject and her writing reveals her ignorance) is like that, I'm not sure what good it does to make note of it.

Mammography and colonoscopy screening have been demonstrated to reduce mortality. Bone scans are not recommended for routine screening anyway. Blah, blah, blah....

Linda

[Bob Klase]

Link doesn't work for me.

Aggressive cancer is incurable anyway, so it doesn't really help to find it earlier or later.

I believe that's a very dangerous view. The later it's found the more incurable it's likely to be.

[Gord_in_Toronto]

I can't get the first url to open for me but right off the top of my head I suggest the colonoscopy screening for colorectal cancer is very effective and saves many lives. Prostate cancer is anamolous because it is very slow to kill you and many sufferers die of something else before it gets to them.

The Cochrane Commish is definitely not Woo.

[paximperium]

Nothing beats a badly written article from someone who knows absolutely nothing about this topic. It starts out by poisoning the well with an unjustified assertion(Half of things done are none Evidence based) which she just pulled out of thin air and then she moves along and makes a dangerous and downright false claim that screening exams to not save lives. I guess she must have not read anything on colonoscopies or mammograms?

[fls]

I can't get the first url to open for me but right off the top of my head I suggest the colonoscopy screening for colorectal cancer is very effective and saves many lives. Prostate cancer is anamolous because it is very slow to kill you and many sufferers die of something else before it gets to them.

The Cochrane Commish is definitely not Woo.

Umm....what about my link?

The Cochrane Collaboration is not woo, but it also doesn't say what she said it says.

Linda

[Wowbagger]

I'll have to double-check my sources, but I do recall someone mentioning that the words "evidence based" have a specific, technical meaning in medical research.

Just because something is not considered "evidence based" does not necessarily mean there is no evidence that it works, it just does not meet the specific standards of the technical definition.

If clinical studies show a drug is clearly effective at something, that is evidence. But, if the specific mechanism is not known, yet, it might not be considered "evidence based".

Anyone can correct me if I am wrong.

[sgf8]

Maybe I need to re-read the original letter but I'm not sure, is she saying that we don't need medical scans and checkups because we are all going to die or not anyway and the medical world isn't able to help us out much? Please correct me if I am wrong.

I checked out some other columns this woman has written trying to understand where her motivation is coming from. She wrote an article about it not being important to wear a bike helmet when riding. She has been car free for 3 months and feels that it is safer (she does a lot of claiming) to ride along with cars and not in bike lanes. She says it pisses off the car drivers but she does not care because it is safer that way. I think her point is that we need to make car drivers more responsible and careful and not worry about bike riders wearing helmets.

She has two children (wonder if she feels this way when they are riding in traffic without a helmet?) "Don't bother with the helmet today sweetie, your hair looks so pretty the way it is...and don't forget to ride like you are a car, in fact if you are tired just hang on the bumper of the nearest SUV, just swing off when you get near where you need to be..."

Susan

[SRW]

Maybe I need to re-read the original letter but I'm not sure, is she saying that we don't need medical scans and checkups because we are all going to die or not anyway and the medical world isn't able to help us out much? Please correct me if I am wrong.




It is very difficult to pars her words, but she seems to believe that the body will take care of most problems just fine, and medical intervention is not need as a rule.

Why find out if you might have cancer, a flying saucer may land on your head anyway...

[Gord_in_Toronto]

Umm....what about my link?

The Cochrane Collaboration is not woo, but it also doesn't say what she said it says.

Linda

Geeze! How fast do you want me to post? :p I always try and verify whatever I say with a quick Google. Sometimes it saves me from looking like an absolute idiot!

[fls]

I'll have to double-check my sources, but I do recall someone mentioning that the words "evidence based" have a specific, technical meaning in medical research.

Just because something is not considered "evidence based" does not necessarily mean there is no evidence that it works, it just does not meet the specific standards of the technical definition.

If clinical studies show a drug is clearly effective at something, that is evidence. But, if the specific mechanism is not known, yet, it might not be considered "evidence based".

Anyone can correct me if I am wrong.

My impression is that some people (it seems to be an American thing) think that "evidence-based" is the same thing as (or consists mainly of) systematic reviews (i.e. the Cochrane reviews). The idea (the movement originated in Canada and something was lost in translation?) is much broader than that - more in line with what you described.

Linda

[casebro]

Hmmm. There is some testing that sounds more efficient than it really is. The common "relative risk" vs "comparative risk" comes onto play here. One example is "Downs syndrome is 10 time more common in older women" (relative risks) vs The comparative risk is 1 in 10,000 vs 1 in 1,000 for older women. So even if you are over 40, having a Downs child is far from a realistic worry- unless you plan on having close to 1,000 babies.

Statin drugs help 2 1/2% of patients after five years of treatment, yet are said to lower the heart attack rate by a whopping 30%.

Safety glasses save worker's comp insurors, but what are the odds of any particular worker "losing an eye"? You wear glasses and facemask both, and still damage both eyes.*

So, many risks/benefits are only comparable in a large numbers game.

Modern scanning technologies do turn up lots of harmless little anomalies. Things that cost the insurors to have investigated. *

I'd say "evidence based efficacy" depends a lot on where you are standing.

* personal anecdote available, risk factor of 1.

[blutoski]

I'll have to double-check my sources, but I do recall someone mentioning that the words "evidence based" have a specific, technical meaning in medical research.

Just because something is not considered "evidence based" does not necessarily mean there is no evidence that it works, it just does not meet the specific standards of the technical definition.

If clinical studies show a drug is clearly effective at something, that is evidence. But, if the specific mechanism is not known, yet, it might not be considered "evidence based".

Anyone can correct me if I am wrong.

That's my impression: EBM is both a specifically defined movement within medicine, and also a general description for just having good evidence.

In lifeguarding, we're also seeing a shift toward attempts to establish an evidence-based practice.

To give you a description of the difference between the two meanings, when a victim has sliced into his leg, there is EBM that applying pressure directly above the wound works better than applying pressure proximally or distally, even if you know only a vein has been punctured (as opposed to an artery).

What's not EBM is evidence that there's any good reason to try to stop bleeding in the first place. For that we only have "standard" evidence and common sense.

[paximperium]

My impression is that some people (it seems to be an American thing) think that "evidence-based" is the same thing as (or consists mainly of) systematic reviews (i.e. the Cochrane reviews). The idea (the movement originated in Canada and something was lost in translation?) is much broader than that - more in line with what you described.

Linda

Not really.
Evidence Based Medicine(EBM) is composed of different but complementary components. One is the mindset of physicians, which is to approach treatment and clinical care based on available evidence. Prior to EBM, most physicians based most of their care on anecdotal experience and things they learned in medical school. The other component is a public health approach to medicine. Does X work? Is X cost effective? It is also a way to gauge the quality of care(does heart attack patient's get aspirin etc.) compared to other physicians or hospitals.

EBM started in Canada and the UK, I believe but has become a significant movement within the US medical system. However, there are fears that insurance and good ol' medicare is going to use bad EBM as a way to cut payments to doctors.

EBM does not just mean review articles but an approach to medical treatment. It is essentially demanding that physicians apply the Scientific Method when using medicine.

[paximperium]

Hmmm. There is some testing that sounds more efficient than it really is. The common "relative risk" vs "comparative risk" comes onto play here. One example is "Downs syndrome is 10 time more common in older women" (relative risks) vs The comparative risk is 1 in 10,000 vs 1 in 1,000 for older women. So even if you are over 40, having a Downs child is far from a realistic worry- unless you plan on having close to 1,000 babies.

Statin drugs help 2 1/2% of patients after five years of treatment, yet are said to lower the heart attack rate by a whopping 30%.

Safety glasses save worker's comp insurors, but what are the odds of any particular worker "losing an eye"? You wear glasses and facemask both, and still damage both eyes.*

So, many risks/benefits are only comparable in a large numbers game.

Modern scanning technologies do turn up lots of harmless little anomalies. Things that cost the insurors to have investigated. *

I'd say "evidence based efficacy" depends a lot on where you are standing.

* personal anecdote available, risk factor of 1.

Here's a funny story.
A medical computer simulation company that I had ties to in the past used computer simulations to model changes in health in the population. So, they decided to model a what if scenario:

What if you put statins(cholesterol), aspirin(heart) and prozac(depression) into the US water supply?

Taking into account allergic reactions, side effects etc. the US would save more money in medical savings and the economy from heart disease and depression that we could pay off a substantial chunk of the US debt in about 10 years.

Just a thought.

[blutoski]

Here's a funny story.
A medical computer simulation company that I had ties to in the past used computer simulations to model changes in health in the population. So, they decided to model a what if scenario:

What if you put statins(cholesterol), aspirin(heart) and prozac(depression) into the US water supply?

Taking into account allergic reactions, side effects etc. the US would save more money in medical savings and the economy from heart disease and depression that we could pay off a substantial chunk of the US debt in about 10 years.

Just a thought.

Well, that's certainly a story. The idea is ridiculous, of course.

[paximperium]

Well, that's certainly a story. The idea is ridiculous, of course.

Imagine the savings!!! What are you? An anti-fluoride nutjob? :)

They never meant to be taken seriously but I believe the results were published in a medical journal...if only I can remember which one...

[fls]

Not really.
Evidence Based Medicine(EBM) is composed of different but complementary components. One is the mindset of physicians, which is to approach treatment and clinical care based on available evidence. Prior to EBM, most physicians based most of their care on anecdotal experience and things they learned in medical school.

Aren't you a doctor? How long have you been practising - i.e. does your experience precede the EBM movement? What was the point of all those clinical experiments prior to 1990 if doctors didn't use the available evidence?

EBM does not just mean review articles but an approach to medical treatment. It is essentially demanding that physicians apply the Scientific Method when using medicine.

My impression comes partly from Skeptigirl and Harriet Hall claiming that science-based reasoning has not been a necessary component of EBM. This was news to me, but Skeptigirl was very insistent on this point. Are you a US physician? I'd be happy to hear that the impression they gave me is not representative. :) I've practised in the US, but my experience is not typical.

Linda

[Mojo]

Over here, they seem to be working to reduce that percentage:

http://www.timesonline.co.uk/tol/life_and_style/health/alternative_medicine/article4317985.ece

[Travis]

http://www.montereyherald.com/joycolangelo/ci_9939596?
Prostate screening shows evidence as well—evidence that we are not saving any lives by testing. More men will die with prostate cancer than of it and 90 percent will live 15 years without treatment. Aggressive cancer is incurable anyway, so it doesn't really help to find it earlier or later.

My dad had super aggressive prostate cancer that was caught early. He had one surgery and has been cancer free ever since.

Aggressive cancer is incurable? Hardly.

[paximperium]

Aren't you a doctor? How long have you been practising - i.e. does your experience precede the EBM movement? What was the point of all those clinical experiments prior to 1990 if doctors didn't use the available evidence?
I'm a youngin. I've completed my residency and have been in practice for 3 years now. I started medical school just as the whole EBM started to take off.

In discussion with some of the older physicians, prior to EBM, each physician decides to follow or ignore studies as they see fit. Many of what was done was educated guesses which is kinda of evidence based but was never really put together. An example is the diagnosis of neck fractures after trauma. Prior to the huge NEXUS and Canadian C-Spine Rule studies, there was no consensus to determine who needed and Xray Vs. those that did not. So many docs either Xray-ed everyone with neck pain or some used their own made up criteria.

I had started medical school just as EBM was taking off and am comfortable with it. Some of the older docs don't like it because many of the EBM based studies basically create flow charts and scoring systems...they call it "cook book" medicine and feel like it takes away their decision making, which is silly since physicians still can change treatment as they see fit.



My impression comes partly from Skeptigirl and Harriet Hall claiming that science-based reasoning has not been a necessary component of EBM. This was news to me, but Skeptigirl was very insistent on this point. Are you a US physician? I'd be happy to hear that the impression they gave me is not representative. :) I've practised in the US, but my experience is not typical.

Linda
That is true. Science-based reasoning isn't a major part of EBM but it is a part that is being taught in medical schools. I have noticed a generational difference from when I started med school to today. Once some of the older docs were poo-pooing EBM in med school and nowadays the trauma surgeons, even the older ones, are changing the way they resuscitate gun shot wounds due to brand new data from Iraq.

While many community docs are still not very science-based in their approach to medicine, EBM is changing the way medicine is practiced...to a degree. Certain sociological, medico-legal etc. factors are involved. An example would be ear infection in kids. Most studies show that it is okay to not treat ear infections in kids but due to parents expectations and persistence, we almost always give antibiotics...it isn't wrong to treat ear infections with antibiotics because it does work but it isn't necessary.

[Ivor the Engineer]

I wish 80% of my 'sick' designs got better over the weekend.:)

I've got a FPGA - External RAM interface that conks-out at 90C. Time to insert some probes...

[technoextreme]

I wish 80% of my 'sick' designs got better over the weekend.:)

I've got a FPGA - External RAM interface that conks-out at 90C. Time to insert some probes...
You never had that happen before? I've had that happen a couple of times.:)

[geni]

I'll have to double-check my sources, but I do recall someone mentioning that the words "evidence based" have a specific, technical meaning in medical research.

Just because something is not considered "evidence based" does not necessarily mean there is no evidence that it works, it just does not meet the specific standards of the technical definition.

If clinical studies show a drug is clearly effective at something, that is evidence. But, if the specific mechanism is not known, yet, it might not be considered "evidence based".

Anyone can correct me if I am wrong.

From what I recall the percentage is pushed up because double blind testing of surgery is tricky and even single blind testing is not commonly done.

[fls]

I'm a youngin. I've completed my residency and have been in practice for 3 years now. I started medical school just as the whole EBM started to take off.

In discussion with some of the older physicians, prior to EBM, each physician decides to follow or ignore studies as they see fit. Many of what was done was educated guesses which is kinda of evidence based but was never really put together.

I see. You are going by what people have told you, rather than direct experience.

An example is the diagnosis of neck fractures after trauma. Prior to the huge NEXUS and Canadian C-Spine Rule studies, there was no consensus to determine who needed and Xray Vs. those that did not. So many docs either Xray-ed everyone with neck pain or some used their own made up criteria.

I had started medical school just as EBM was taking off and am comfortable with it. Some of the older docs don't like it because many of the EBM based studies basically create flow charts and scoring systems...they call it "cook book" medicine and feel like it takes away their decision making, which is silly since physicians still can change treatment as they see fit.

My experience crosses the pre and post-EBM movement. From my perspective, the transition was fairly smooth as it simply provided a more formal framework for what was already happening (although, as I mentioned earlier, my experience may not be typical as it has mostly been at academic centres). You gave an example of criteria that were developed since 1990, but there are many examples that pre-date it, such as the Goldman criteria.

Of course doctors will complain if they perceive that they are being told what to do. That can't be helped. :)

That is true. Science-based reasoning isn't a major part of EBM but it is a part that is being taught in medical schools. I have noticed a generational difference from when I started med school to today. Once some of the older docs were poo-pooing EBM in med school and nowadays the trauma surgeons, even the older ones, are changing the way they resuscitate gun shot wounds due to brand new data from Iraq.

While many community docs are still not very science-based in their approach to medicine, EBM is changing the way medicine is practiced...to a degree. Certain sociological, medico-legal etc. factors are involved. An example would be ear infection in kids. Most studies show that it is okay to not treat ear infections in kids but due to parents expectations and persistence, we almost always give antibiotics...it isn't wrong to treat ear infections with antibiotics because it does work but it isn't necessary.

That is also my impression. Whether or not individual doctors practice EBM and to what extent science-based reasoning is brought into it hasn't really changed.

Linda

[SRW]

My dad had super aggressive prostate cancer that was caught early. He had one surgery and has been cancer free ever since.

Aggressive cancer is incurable? Hardly.

Glad to hear your dad was saved, most probably because it was discovered in a very simple and routine screening.

[SYLVESTER1592]

In discussion with some of the older physicians, prior to EBM, each physician decides to follow or ignore studies as they see fit. Many of what was done was educated guesses which is kinda of evidence based but was never really put together. An example is the diagnosis of neck fractures after trauma. Prior to the huge NEXUS and Canadian C-Spine Rule studies, there was no consensus to determine who needed and Xray Vs. those that did not. So many docs either Xray-ed everyone with neck pain or some used their own made up criteria.


I have to agree with you on that...
It's still true outside of the US. As Linda already stated, doctors don't like the feeling of being told what to do. But the level A or B evidence is almost never ignored. Guidelines are great, evidence is great, but at the end of the day it's still your choice as a doctor to draw your conclusion and choose the right guideline or EB treatment. If only one conclusion was possible and only one treatment was correct with guidelines that were suitable for all patients... We wouldn't need doctors, nurses would be more then good enough. This, ofcourse is not the case. EBM can't and won't tell doctors what to do, it just makes their choices easier, siffting through the large amount of studies and weighing the outcomes.
But that's just my humble opinion... :covereyes

SYL :)

[shadron]

I wish 80% of my 'sick' designs got better over the weekend.:)

I've got a FPGA - External RAM interface that conks-out at 90C. Time to insert some probes...

Checkout software engineering. Things seem to come and go; attitude seems to have a lot to do with it, and of course there's the late Friday afternoon factor...

[Miss_Kitt]

Hi, all. I first must humbly observe that I am not a doctor, nor medical student--and due to my not having discovered that I LOVE medicine until a few years ago, will not be able to become one. (Starting med school at 44 is just not happening.) Nonetheless, I consider myself an educated observer of medicine, become more educated all the time.

First to Linda: Your posts are always a pleasure. I've been using the Homeoproofer thread for my entertainment reading, and I bow to your supreme patience and pithy focus. You're even kindly to fools, and I respect your knowledge and your communication skills.

To Pax: First, congrats on entering the field! We need good doctors more than ever. However, I am a little disappointed to hear that you prescribe antibiotics for ear infections just because the parents are squawking. Surely that's not a good idea? Unnecessary use of antibiotics is implicated in the creation of resistant strains; and even if the target microbe is killed, you still have the possible side-effects of offing some normal intestinal flora--leading to gastric discomfort--and/or yeast infections following the course of anti-b's.

I am a parent, and I take my daughter to see a doctor when it's clear that something's wrong and it's not getting better--but I'm perfectly okay with, "She'll be better in a few days," or "It's viral, rest and fluids, light activity as she feels up to it; but don't send her to school unless you want to give it to everyone." I'm also okay with, "That's definitely infected, we're seeing a lot of this," and a prescription as needed. Maybe because my doctor knows I want to be an informed consumer, she will discuss with me what she thinks the likelihood is of it getting better without treatment.

Am I totally confused on this? I just think that handing out drugs that aren't necessary is definitely a bad idea. :confused:

Thanks in advance for the additional education, MK

[MG1962]

My dad had super aggressive prostate cancer that was caught early. He had one surgery and has been cancer free ever since.

Aggressive cancer is incurable? Hardly.

I recently lost a Father-in-law to this cancer. He started stanard treatment, then progressed to needing an operation. He was 78 and refused the surgery. With surgey they gave him 4 years. Without - a maximum of 2 years.

He closed his innings at 3 years 9 months. Apparently it is thought that the orginal treatment worked far better than expected, but doctors dont seem to know the exact reason why.... but they are working on it

According to the orginal article, should this treatment be stopped because we dont know why it works so well. Or continue such treatments while exploring the statisitcal data to see if this was a one off, or evidence of a more efficent treatment

[Dr. Imago]

Of course doctors will complain if they perceive that they are being told what to do. That can't be helped. :)

That's not really the problem, Linda. In many cases we're being told we can't do something because it doesn't fit into the "protocol". Fact is, most patient's I've encountered haven't read the studies or the textbooks (you, as a physician, know what I mean by that) ;) . And, some of this purported "evidence-base" is either contradictory or not applicable in individual circumstances.

The reality is that we make medical decisions based on three clinicina-decision criteria: fact, fiction, or fetish. There are clearly things that work, and have a solid evidence base. For example, putting post-MI patients on a beta-blocker, statin, baby aspirin and, if tolerated, angiotensin inhibitor or blocker (i.e., "fact"). These can be applied to broad populations.

There are things that some clinicians continue to do despite good evidence that they don't work (i.e., "fiction").

And, then there are areas where it could go either way, and it comes down to invdividual practitioner preference (i.e., "fetish"). In much of this, you will find that there is a wide variation in the evidence base. I can think of several specific examples that are germane to my field of practice, anesthesiology, but suffice it to say that we lump these into the "there is more than one way to climb a tree" category.

What I personally object to is the "protocoling" of medicine; namely, that everyone must get the same treatment everytime. I think the pendulum swings, and right now it's swinging towards "standardization is the best medicine". That's the bastardization of EBM that I object to.

And... while I'm at it... the Cochrane Collaboration may not be "woo", but it sure as hell doesn't have all the answers either. Meta-analysis... well, I just don't think it's as "rigorous" or broadly applicable of a methodology as others would hold it out to be.

~Dr. Imago

[paximperium]

To Pax: First, congrats on entering the field! We need good doctors more than ever. However, I am a little disappointed to hear that you prescribe antibiotics for ear infections just because the parents are squawking. Surely that's not a good idea? Unnecessary use of antibiotics is implicated in the creation of resistant strains; and even if the target microbe is killed, you still have the possible side-effects of offing some normal intestinal flora--leading to gastric discomfort--and/or yeast infections following the course of anti-b's.

I am a parent, and I take my daughter to see a doctor when it's clear that something's wrong and it's not getting better--but I'm perfectly okay with, "She'll be better in a few days," or "It's viral, rest and fluids, light activity as she feels up to it; but don't send her to school unless you want to give it to everyone." I'm also okay with, "That's definitely infected, we're seeing a lot of this," and a prescription as needed. Maybe because my doctor knows I want to be an informed consumer, she will discuss with me what she thinks the likelihood is of it getting better without treatment.

Am I totally confused on this? I just think that handing out drugs that aren't necessary is definitely a bad idea. :confused:

Thanks in advance for the additional education, MK

The vast majority of Otitis Media are viral. A subgroup is bacterial and even while many bacterial otitis will clear on its own, there is a risk of ear drum perforation and even infection of the mast air cells of the skull and meningitis...I've a half dozen of these.

The current guidelines concerning treatment of Otitis Media goes both ways. The current recommendation is to not treat it, IF they are able to be seen and followed up by their pediatrician within 24hours.

If they are unable to be followed up, they recommend treating the otitis with antibiotics.

I work at a County hospital where over 3/4 of my patients are poor and have Medi-Cal or no insurance. Their followup rate if I don't treat is not very good. Taking that into account, the benefit on the decision to treat outweighs the risk to the child if a bacterial infection is not caught on followup.

Nothing beats taking financial and social issues into account when making medical decisions.

PS: You can still do medicine. Some of the students in my class were in their fourties and even one who was in her fifties.

[Miss_Kitt]

PaxI -- Thanks for the info. I'm guilty of thinking in terms of my own experience, which includes people going to the doctor as needed at a (relatively) low cost--not the "The office fee of $40 is coming out of the bills" world. You're right, if you are looking at no realistic follow-up chance, that's a different picture.
Ditto on the thought that people are confident in their ability (or having the ability) to make a judgement call on whether or not to go for the Rx. Again, my life experience involves a level of education and resources that is hardly universal in this country, let alone the larger world.

You're the 2nd person who has suggested that it's truly possible for someone my age to start the long road to an MD. I am fascinated by the human body--its complexities, its beauty, its remarkable self-adjustment and feedback systems--and the level of knowledge we are achieving even compared to 20 years ago is amazing! It's a tantalizing thought; but based upon my sister's (and some other friends') stories, I doubt I'm up to the physical rigors of studying at that level, let alone the sleep-deprivation experiment / survivalist training course we call "internship". Plus, realistically, I'd be in debt on my deathbed. Figure, oh, 10 years for BS plus med school, that makes me nearly 60 before I start making (as opposed to spending)money out of my obsession. But if I was single, or at least childless, I might try it anyway. ;)

[fls]

That's not really the problem, Linda.

I was thinking of the 'complaint' as unreliable. Since we complain regardless of whether or not what we are told to do is reasonable, we can't use complaints as a measure of whether or not what we are told to do is unreasonable. :)

I do agree that the complaints can be valid.

What I personally object to is the "protocoling" of medicine; namely, that everyone must get the same treatment everytime. I think the pendulum swings, and right now it's swinging towards "standardization is the best medicine". That's the bastardization of EBM that I object to.

Yes, that's the bastardization I object to, as well.

And... while I'm at it... the Cochrane Collaboration may not be "woo", but it sure as hell doesn't have all the answers either. Meta-analysis... well, I just don't think it's as "rigorous" or broadly applicable of a methodology as others would hold it out to be.

~Dr. Imago

It's odd that you think of the Cochrane Collaboration as about Meta-analysis, but it confirms my impression that most people seem to think of it that way now. It's really about Systematic Review.

However, I view the Cochrane Collaboration as the 'diagnostic test' component of medical evidence. Pretending that EBM is the Cochrane Collaboration is like pretending that medical decision making is the listing of the results of diagnostic testing.

Linda

[casebro]

Viral or bacterial, what sufferers of ear infections need is PAIN MEDS!

I had pair of ear infections last year, as an adult. I know that I can't out run the pain, I tried it. Worse than my ruptured disc pain, when I opened the car door to go stand up- at 60 mph! Vicodin helped me out, but kids don't usually have a bottle lying around. Does EBM show that kids can feel pain too? I think children are waaaaay under medicated for pain.

[kookbreaker]

I checked out some other columns this woman has written trying to understand where her motivation is coming from. She wrote an article about it not being important to wear a bike helmet when riding. She has been car free for 3 months and feels that it is safer (she does a lot of claiming) to ride along with cars and not in bike lanes. She says it pisses off the car drivers but she does not care because it is safer that way. I think her point is that we need to make car drivers more responsible and careful and not worry about bike riders wearing helmets.


While riding without a helmet may be stupid, not riding in the bike lane is not automatically stupid. Many bike lanes are poorly designed or are afterthoughts to road design and may actually increase the risks to riders than over riding in the street.

Her reasoning may be unsound, but not all her conclusions are unsound.

[patrick767]

A few years back my personal physician told me that they do many things that don't have strong medical studies supporting them. In fact I'm currently on a prescription for an "off label" purpose, meaning that it's treating a problem that it wasn't developed to treat, but it's working for me so my doctor is sticking with it.

However, my impression was that the physicians' anecodote based treatments are more typically for the minor problems that are in issue of patient comfort/quality of life. They're not trying to cure cancer that way and at least in my doctor's case he's not pushing quack remedies like herbal supplements and whatnot. He's just willing to try a treatment when the expense and risk are low that has worked for other patients, even if specific evidence from scientific studies isn't strong. I think you'll find that general practitioners take this approach on a regular basis, particularly in dealing with minor health issues.

On the other hand, Joy Colangelo sounds like a fool. Wear your helmet.

[jli]

What I personally object to is the "protocoling" of medicine; namely, that everyone must get the same treatment everytime. I think the pendulum swings, and right now it's swinging towards "standardization is the best medicine".

I´m not so sure that the pendulum is swinging in that direction these years. In our multidisciplinary team we discuss each and every patient and plan the individual treatment. Of couse many of them fit into one of the standard protocols, but sometimes they don´t. And in these patients they (I´m more into diagnostics) do individualize treatment. It is my impression that this is what is happening everywhere - but I could be wrong.

[Miss_Kitt]

I wanted to bring up a little episode of public paranoia we had up here in the Seattle area last year. The UW wanted to study the relative effectiveness of different strategies for treating victims of automobile accidents, shootings, heart attacks while on scene / going to the ER. The plan was to randomly assign people into groups, and then test differing types of fluids given; or, for heart attacks, how long to do just CPR before going to electrical defib. The protocol would end when the patient was turned over to the ER staff, and patients would be told they had been part of the study (though not which group they were in).

People freaked when they heard about this, and there was a giant media hype. "People should not be guinea pigs," was the battlecry. I remember hearing one of the researchers patiently explaining to a local radio talkshow host that there are not studies on how effective the standard procedures are, they were just arrived at over time...and how this could actually produce better procedures. Needless to say, this was completely ignored. I think they may even have had to abandon the study due to public furor.

I wonder if this is part of the "what's done in hospitals isn't proven" is meant to convey? That there are some pretty standard things that may not be best practice, or even necessary, but are done because they've been done since before the current crop of physicians were trained.

How do we approach overcoming the public's vast ignorance concerning what constitutes evidence?

[paximperium]

I wanted to bring up a little episode of public paranoia we had up here in the Seattle area last year. The UW wanted to study the relative effectiveness of different strategies for treating victims of automobile accidents, shootings, heart attacks while on scene / going to the ER. The plan was to randomly assign people into groups, and then test differing types of fluids given; or, for heart attacks, how long to do just CPR before going to electrical defib. The protocol would end when the patient was turned over to the ER staff, and patients would be told they had been part of the study (though not which group they were in).

People freaked when they heard about this, and there was a giant media hype. "People should not be guinea pigs," was the battlecry. I remember hearing one of the researchers patiently explaining to a local radio talkshow host that there are not studies on how effective the standard procedures are, they were just arrived at over time...and how this could actually produce better procedures. Needless to say, this was completely ignored. I think they may even have had to abandon the study due to public furor.

I wonder if this is part of the "what's done in hospitals isn't proven" is meant to convey? That there are some pretty standard things that may not be best practice, or even necessary, but are done because they've been done since before the current crop of physicians were trained.

How do we approach overcoming the public's vast ignorance concerning what constitutes evidence?

Oh great, the Seattle EMS folk...just kidding :D

Seattle has the best EMS system in the country and they really really do things in their system that I believe should be left the an ER doc. They are really good though and many EMS research(I'm ignoring those money soaked rich Canadians with their huge standardized paramedic system) is produced by those guys.

Anyway, there's nothing much you can do. This was part of the furor that occurred after the artificial blood tests done in a bunch of hospitals years ago. They randomized patients from trauma to receive either normal saline or artificial blood to see who does better. The furor was significant since we were apparently "experimenting" on people and what's worst was that many of the centers involved were big academic centers in urban areas, meaning that most of the population involved was black. Not a pretty situation.

Unfortunately the artificial blood was found to have profound sideeffects and that made things worst.

To perform a community based study with no consent(since the patients are unconscious), they did exactly what needed to be done. They needed to notify the public community involved, they needed to have discussions with the community and they needed a media campaign. It is absurdly expensive to do such studies so there needs to be a very good reason to do it. UW apparently decided it wasn't worth it.