Talk:Evidence-based medicine
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[edit] Moved unencyclopedic comment:
- The expert is dead! Long live the expert!
Epidemiology is evidence-based - read epidemiology. Also greatly tightened up the case study bit. - David Gerard 16:30, Jan 16, 2004 (UTC)
- Excuse me, but Epidemiological research is not randomized clinical trial double-blind research. The medical scientism people are definitely laughting at all Epidemiological research. And, case-studies positively were the hot-item before the arrival of evidence-based medicine. If you want it tighter, than make it tighter. It looks good to me, as is. -- Mr-Natural-Health 17:45, 16 Jan 2004 (UTC)
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- Strunk and White are my heroes ;-) - David Gerard 19:20, Jan 16, 2004 (UTC)
[edit] I was invited to write here!
I was invited to write here! I added two objective agruments and they were deleted, of course, without comment. What gives? Was your offer more double talk. Wholesale deletion of text is strictly prohibited. -- Mr-Natural-Health 17:38, 16 Jan 2004 (UTC)
Did you write "Belief in only one way of doing medical research totally trashes the branch of medicine called epidemiology.
Is this the deletion you are talking about? Because David has commented. See above. Also the fact that you were invited to write an article does not mean that other people cannot edit it. theresa knott 17:49, 16 Jan 2004 (UTC)
Well excuse me, but David's comments actually support my position that an article on Medical Scientism is required. David says epidemiology is valid science. I say that epidemiology is valid science. But, the medical scientism people say that it is quackery.
Nutrition used to treat medical conditions is classified as CAM research by PubMed. Nutrition is not quackery becuase it is based on epidemiological research. Therefore, there is more than one way of medical research, and the Medical Scientism people are positively full of POV. Frankly, I am tired of having to carry on 5 conversations at the same time, with the same biased person. -- Mr-Natural-Health 18:22, 16 Jan 2004 (UTC)
- "But, the medical scientism people say that it is quackery." - Refs? (And not ones requiring a subscription.) - David Gerard 19:12, Jan 16, 2004 (UTC)
- ???? We cannot quote comments made by RK and his other cronies. Just follow the talk pages. -- Mr-Natural-Health 19:30, 16 Jan 2004 (UTC)
- Just a comment: Please do not use PubMed classifications as absolute truth. PubMed CAM classifications are nothing more than a search filter. You can view the contents here: [1]. And just to disprove the assertion above, here is an article about the effects of nutrition on heart problems, which is not classified as CAM: [2]. Rasmus Faber 23:27, 16 Jan 2004 (UTC)
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- No problem! It is easy for YOU to be confused! Searching on PubMed with this text string:
- cam [sb] nutrition
- yields 14292 hits.
- Searching on PubMed with this text string:
- cam [sb] epidemiology
- yields even more hits at 17073.
- Ergo, my point is perfectly valid and is not POV. -- Mr-Natural-Health 02:01, 17 Jan 2004 (UTC)
- No problem! It is easy for YOU to be confused! Searching on PubMed with this text string:
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- I was not claiming that your point was POV. Only that it used a bad argument. PubMed does not classify nutrition or epidemiology as anything. Rather when entering "cam [sb]" into the search field, they expand your search string into a larger search string, which among other things include "supplement AND vitamin c". To use your argument: here is an article, which popped up when searching for cam [sb] with the limit : Randomized Controlled Trial: [3]. So chemotherapy and stem-cell transplantion is CAM?! Probably not, but the article contained the right combination of keywords. Likewise with nutrition and epedemiology, which often deals with vitamins and supplements, and thus often contains words also associated with CAM. Rasmus Faber 12:19, 17 Jan 2004 (UTC)
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- I still consider YOUR POINT, too minor to even bring up. I never make absolute claims, because they are absolutely always wrong. I am not responsible for how PubMed has managed to bungle up their database.
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- What I find important/interesting is that the very first controlled research study ever done was done in the 1700's on the subject of scurvy in the British Navy. The concept of using diet rather than a medication (like seawater) to treat the medical condition called scurvy classifies it as Alternative Medicine as well as a Natural therapy. The fact that it is also classified as nutrition, etc., etc., etc., and that medicine will also claim it as one of their very own studies is totally besides the point. -- Mr-Natural-Health 16:03, 17 Jan 2004 (UTC)
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- We now begin discussing the definition of Alternative Medicine. I have moved the discussion to Talk:Alternative medicine. Rasmus Faber 08:13, 19 Jan 2004 (UTC)
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What in the world are you talking about? Boy are you strange! -- Mr-Natural-Health 01:11, 20 Jan 2004 (UTC)
The case study para - should that be in the case study entry? - David Gerard 19:20, Jan 16, 2004 (UTC)
- No! Being that evidence-based medicine is all about population evidence, more than half a sentence on case study should be present in the criticism section. -- Mr-Natural-Health 19:37, 16 Jan 2004 (UTC)
Medical Scientism cannot be referenced!
The mantra of medical scientism is randomized clinical trials, double-blind, peer reviewed, studies published in respectable journals. Epidemiological research is not the randomized clinical trials and double-blind stuff that drug research is made of.
If any one element of this mantra is missing, then that published research study is classified as being invalid research. This kind of decision is made quite arbitrarily by the medical scientism people. And, their mantra clearly renders the vast majority of all published health research invalid and virtual quackery by implication.
The primary treatment method of medicine is medication. And, their mantra is clearly designed for drug testing. So, forcing a drug testing paradigm upon other kinds of health research is patently absurd. Unfortunately, people like RK don't see it that way.
This phenomenon of medical scientism is quite real because it dominates all science newsgroups, mailing lists and of course the health related articles in Wikipedia.-- Mr-Natural-Health 21:00, 16 Jan 2004 (UTC)
- This is the Evidence-based medicine article, not the Medical Scientism article. There's a book, there's a website. There is reference material for you to back up your assertions with. - David Gerard 10:43, Jan 17, 2004 (UTC)
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- I know what Evidence-based medicine is, probably more so than you do. According to BMJ physicians are supposed to spend on average 2 hours researching (ie, as a transitive verb) the best medical treatment for each patient that walks through their door; even though they spend an average of only 10 minutes in each visit with a patient. EBM in many respects has a lot in common with patient empowerment as any patient expecting to survive medical treatment better be in control to the point of making their own decisions.
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- I have already defended my position on the talk pages of both Medical Scientism and Scientism. Whether or not I can or cannot come up with a reference is purely an academic question. In Alternative medicine I have come up already with about 20 references. If you were to care to look, the reference section of Alternative medicine is actually longer than the text. Evidence-based medicine frankly is not even set up for a serious discussion of the topic. Your method of referencing is too cumbersome to fool with.
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- Set up a proper Reference Section with my references to research etc. fully disclosed and I might consider spending more time on improving this article. -- Mr-Natural-Health 15:50, 17 Jan 2004 (UTC)
[edit] reasons for removing material
I removed the following text from the criticism section because the individual assertions are either (1) true but applicable to medical practice in general rather than being specific to EBM, or (2) erroneous, reflecting a misunderstanding by the contributor of what EBM is and isn't.
Removed material
Some treatments take a more holistic approach, which may be difficult to fit into a testing model that assumes the patient is a passive object acted upon by the treatment.
EBM includes no "assumption that the patient is a passive object." The primary texts of EBM explicitly include the patient's individual values and preferences and provide methods for judging treatment outcomes that are not restricted to drug treatment.
Critics also raise conflict of interest. Journals such as the New England Journal of Medicine, The Lancet, JAMA, and the British Medical Journal have been unable to prevent papers ghostwritten by pharmaceutical companies from being published. These same pharmaceutical companies are a primary source of funding for medical and drug research. In some cases, doctors listed as authors on ghostwritten research papers did not review the raw data, only tables compiled by a medical writing company. (See also Flanagin A, Carey LA, Fontanarosa PB: Prevalence of articles with honorary authors and ghost authors in peer-reviewed medical journals; Larkin M: Whose article is it anyway?)
Conflict of interest is no more specific to EBM than any other types of journal article. In fact, EBM explicitly encourages awareness of sources of information and potential conflict of interest.
Some critics also claim that evidence-based medicine seems more concerned with the job security of researchers than with solving health problems.
You could say this about anybody you don't like. Doesn't belong in an encyclopedia.
Long before evidence-based medicine came along, case studies were an acceptable form of medical research. Case study methodology can be applied effectively to the study of men with chronic coronary heart disease, for example. "Case study methodology can be used as a creative alternative to traditional approaches to description, emphasizing the patient's perspective as being central to the process. Contemporary practitioners and researchers have come to appreciate the subjective richness of patients recounting their experience and the meanings implicit in them to help guide practice." (Zucker, DM: Using Case Study Methodology in Nursing Research)
The importance of the individual patient in the case study method runs counter to evidence-based medicine's emphasis on population evidence.
EBM does not reject case studies or any other type of evidence; it provides criteria for comparing the usefulness and strength of different types of evidence for a specific purpose. The quoted paragraph is perfectly true but perfectly irrelevant to EBM.
However, whereas in the past population trials have had to group patients according to very broad criteria such as age or according to basic parameters such as blood pressure, with increasing access to comprehensive genetic and physiological testing future trials may well be able to combine the best aspects of large scale epidemiology with the detailed investigation of individual patients. That is, the trials will be of thousands of 'individuals' and the data provided by increasingly be more relevant and more easily applied to the patient before the doctor.
Again, probabably true but certainly not a criticism of EBM. This is simply an assertion that new evidence based on new technology will be better because more variables can be taken into account.
I'd be happy to defend specific points if anyone disagrees. alteripse 14:52, 15 Jan 2005 (UTC)
[edit] Possible revisions to Criticism section
Regarding the first part of the first sentence of the Criticism section: "Critics of evidence-based medicine state that doctors were doing these things already..." Without specific reference to what the author meant by "these things", the point is unclear. Is the author attempting to say that doctors were already practicing evidence-based medicine before the term "evidence-based medicine" came into popular usage? If so, why is that in the criticism section? That seems like good support for evidence-based medicine!
Regarding the second part of the first sentence of the Criticism section: "Critics of evidence-based medicine state...that good evidence is often deficient in many areas..." In essence, this particular criticism is directed towards therapies that are performed despite the lack of evidence (i.e. alternative therapies), not those that are performed with evidence (i.e. evidenced-based therapies).
Regarding the third part of the first sentence of the Criticism section: "Critics of evidence-based medicine state ...that the more data are pooled and aggregated the more difficult it is to compare the patients in the studies with the patient in front of the doctor. i.e. EBM applies to populations, not necessarily to individuals." The point here is not clear. Having more information makes it more difficult to treat an individual?! Why is that?
These points should be clarified or the sentence removed. Edwardian 06:37, 25 Apr 2005 (UTC)
EBM deserves to be tagged as "quackery" as much as any other modality. Any attempt to intimidate me into silence is just that: intimidation. 68.226.125.108 21:40, 30 March 2006 (UTC)
One of the key aspects of an EBM approach is to consider how similar this patient is to the patients in the trials. In practice it isn't that hard for a jobbing GP to do, but putting it on an exact numeric basis would be non-trivial. Aggregating like with like, rather than lumping together all studies is expected as well. Midgley May 2005
[edit] in Criticism of...
"In The limits of evidence-based medicine (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11728302&dopt=Abstract), Tonelli argues that "the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand." Evidence-based medicine seems to them to discount the value of the case study."
But ... while a case study is interesting, and is written to stick in our memory, a study of one patient or case also considerably less than directly answers the question of what i should do with another patient who is beside me now.
EBM is pretty good for distinct explicit medical-model conditions, particularly diseases, but I think one area of confusion is around the straw man that this is all one is allowed to do - much of family practice deals with non-disease, and with MUPS (medically unexplained physical symptoms). Midgley
[edit] does this really belng in "criticism of"?
"In managed healthcare systems evidence-based guidelines have been used as a basis for denying insurance coverage for some treatments some of which are held by the physicians involved to be effective, but of which randomized controlled trials have not yet been published." User:Midgley
- It seems basically true to me, and worth mentioning, although I did not add it. The insurance angle was not anticipated by early EBM proponents, but it is fairly easy for an insurance company to deny coverage for something on the basis that published, high level evidence is weak. Of course some might agree and some might disagree as to how strong the evidence should be before insurance covers it. Messy topic, with no pure motives or unbiased perspective from any party. alteripse 23:23, 28 May 2005 (UTC)
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- I comment _only_ on the positioning of it, not on the entirely reasonable points above. Perhaps it should be under a heading of "use of EBH" or "adverse use ..." although that latter is not a NPOV.
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- I wonder to what extent it was not contemplated that health care commissioning and funding organisations (a more general term that fits the NHS and some other European systems as well as the commercial and public ones in the USA) would use an evidence-based approach? I think the idea came in fairly early but I can't cite a source.--Midgley 09:02, 30 May 2005 (UTC)
[edit] Category
Not medicine? Midgley (talk • contribs)
- Adrian, Category:Medical informatics is a subcategory of Category:Medicine. But I agree it should have its own category. JFW | T@lk 08:56, 1 December 2005 (UTC)
EBM should be considered quackery, considering it's minimal contributions to health, its opportunistic exploitation by pharmaceutical companies, and the fact that those who claim to support it conveniently ignore case studies that do not support their modalities. Also, this article is very biased, and any attempt to remove the disputed tag at the top should be considered vandalism. The poor little MafiaDoctors can dish it, but they can't take it. Can anyone say cartel behavior?
- Cartel behaviour.
- No seriously now, it is your tagslapping that is vandalism. Your personal opinion is really irrelevant here; what is relevant is whether large groups of people disagree with the premises of EBM. You will need to quote serious sources. If the Americal Association of Homeopathy publishes a pamphlet against EBM that may be notable. Accusations of complot theories or cartel behaviour are actually buzzwords for Wikipedians to become really sarcastic. Please collaborate like a serious adult. JFW | T@lk 21:38, 3 April 2006 (UTC)
[edit] inaccurate reference
This comment refers to the (current) first paragraph in the section 'criticism of evidence-based medicine'. Starting "Critics of evidence-based medicine maintain...
The Tonelli reference seems to be misrepresented, at least by implication. Tonelli's point is that evidence-based medicine isn't enough by itself. He is strongly opposed to basing patient care solely on EBM, but strongly in favor of EBM as one of several bases for clinical care. His own summary of the article begins "The importance of clinical research for the practice of clinical medicine is immense and undeniable. Yet the type of knowledge gained from clinical research, referred to here as "empirical evidence," is itself insufficient to provide for optimal clinical care."
This is not a criticism of EBM, but rather an inherent limitation of EBM as currently practiced. Would it fit better in a different section?
129.255.102.104 14:51, 9 February 2006 (UTC)bill-morris@uiowa.edu
[edit] criticism section??
The majority of this section seems to be about limitations of EBM, all but the last paragraphs seem supportive of using scientific evidence, but critical of basing all decision on only published articles, and particularly critical of basing all medical decisions solely on published randomized blinded controlled trials. A section title of limitations might be more NPOV.
The last paragraph, and some of the sense in the first two paragraphs do seem to be criticism, but criticism of the misuse of EBM rather then criticisms of EBM. Should that be another category?? As noted in the the opening paragraph EBM is about the the judicious use of the current best evidence, not about refusal to accept any evidence that isn't absolutely positively perfect in every way.
I would also like some references in the last paragraph. my feeling is that such denials have usually been overturned on appeal.
129.255.102.104 15:17, 9 February 2006 (UTC)bill-morris@uiowa.edu
Perhaps the section might be more accurately labeled "limitations" of EBM because no proponents ever advocated the EBM was anything more than a system for assisting the determination of what is best treatment for an individual patient. alteripse 22:38, 30 March 2006 (UTC)
- Agreed -Jim Butler 04:56, 31 March 2006 (UTC)
- Concur, we should change that title. Midgley 15:20, 31 March 2006 (UTC)
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- It looks like most of the criticism is about the overapplication of ebm. For great justice. 20:24, 7 April 2006 (UTC)
[edit] Reorganized and over added comments
To be honest I read this article and thought it was badly organized, but included some good info. I took out some stuff from the 'overview' and placed it in the Qualification section since it was about that, and added a pargraph of three types of EBM practice. --Mikerussell 20:27, 10 May 2006 (UTC)
[edit] make EBM point to disambig page?
Is there support for changing EBM from a redirect to Electronic Body Music to a disambig page that points to Electronic Body Music and Evidence-based medicine? I'm not sure what the technical/political issues are about making this kind of change.
- Done. Gnusmas 07:29, 4 October 2006 (UTC)
[edit] In medicine, evidence can be confusing
http://www.usatoday.com/news/health/2006-10-15-medical-evidence-cover_x.htm Rita Rubin, USA TODAY 10.15.2006
[edit] Daniel Davies
I have once again removed the (alleged - no source given) quote from the Guardian columnist Daniel Davies because (a) I don't see why one among the many thousands of journalists who have made well-informed, fairly-well-informed and downright-misinformed comments on EBM should be given a special place in this article; and (b) what he is quoted as saying about EBM is largely simply wrong. The notion that the "cult of the 5% significance level" plays a key part in EBM is untrue. Gnusmas 08:22, 18 October 2006 (UTC)
[edit] Off label use
Where does off label use of prescription medicines fit into Evidence-Based Medicine ? Should it be mentioned in this article somewhere as an example either or EBM or of non EBM? Or could off label use be a form of alternative medicine ? Robert2957 15:36, 27 October 2006 (UTC)
- OLU can be considered experimental, or can be a useful exploitation of other effects than those normal used. Many medicines have multiple effects. Those that are the primary intended effects are the ones we are hoping to use, while the undesirable effects are called side effects, and are usually of lesser strength than the main effect, and often not even noticed by users. OLU is a common practice in modern medicine. Whether one could call it EBM is another matter. Not all of modern medical practice is adequately evidence-based as yet, but they're working on it.
- In some cases it can be used in ways that go beyond legitimate experimental use, and then it might be classified as "alternative medicine." This use of the word alternative (as is the case with all of "alternative" medicine) is misleading, since a true alternative is a legitimate and logical choice among other effective choices. An alternate choice of an ineffective or even dangerous method or product is not a true alternative. This is one of the basic criticisms leveled against alternative medicine. For more on the subject of definitions, try the bottom of this page, and this one. -- Fyslee 18:00, 27 October 2006 (UTC)
Dear Fyslee,
Thank you for your reply. When you say PLU above, do you mean OLU ? Robert2957 20:28, 27 October 2006 (UTC)
- Yes, that was a typo. Now corrected. Thanks! -- Fyslee 20:34, 27 October 2006 (UTC)
In my understanding, off-label is an administrative definition, not an EBM definition. On-label uses are EBM, but off-label uses may or may not be EBM.
In the US, at least, the "label" refers to the US FDA-approved package insert that comes with the drug and is an extension of the label.
The claims on the label for a particular use have been approved by the FDA, on the basis of clinical trials, and the drug company can only market the drug for those claims.
One or more clnicians, with or without the cooperation of the drug company, can do a clinical trial for a different use, and publish those results, and get high-quality evidence for a *different* use. That would be off-label, but it would still be EBM. The drug company could not advertise that use, however, unless they submitted that additional use to the FDA for approval. Since FDA approval is an expensive and time-consuming process, they often do not (especially with a drug whose patent will have expired by the time the FDA approves a new use).
Alternately, a clinician could appropriately use the drug off-label without high-quality evidence (which is common in e.g. oncology, especially in treating a disease that is too rare for RCTs to be practical).
Alternately, a clinican could inappropriately use the drug off-label for an unproven or inappropriate indication, such as testosterone or DHEA as an anti-aging drug.
(This is an excellent entry, BTW.) Nbauman 15:33, 10 November 2006 (UTC)
- Thanks Nbauman for that excellent explanation. Feel free to contribute. -- Fyslee 19:30, 10 November 2006 (UTC)