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EBM and Sacketts Empiricism

Discussion in 'General Issues and Discussion Forum' started by drsha, Mar 25, 2010.

  1. drsha

    drsha Banned


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    Message to complementary and alternative medicine: evidence is a better friend than power. Andrew J Vickers, Assistant Attending Research Methodologist, Integrative Medicine, Biostatistics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, USA; BMC Complementary and Alternative Medicine 2001, 1:1

    full article
    http://www.biomedcentral.com/1472-6882/1/1

    States in part:
    An evidence-based approach to EBM

    EBM as often presented by (its) advocates is a caricature unrecognizable from EBM as usually understood. (CAM) advocates seem to suggest that the only thing that matters in EBM is scientific evidence, that the only scientific evidence that counts is large randomized trials and that the results of these trials should be followed blindly with no place for clinical judgment and assessment of individual patient needs. Accordingly, a typical argument is that EBM constitutes a 'contrasting rhetoric' to the clinical art, intuition and the idiosyncratic nature of the consultation [1]. It is difficult to credit that anyone who has made an attempt to learn about EBM could believe such a claim. For example, the first paper found by the search "What is evidence based medicine?" on the worldwide web is an editorial by Sackett et al [2]. The very first sentence states that EBM is "about integrating individual clinical expertise and the best external evidence." Later in the article, Sackett claims that "clinicians who fear top down cookbook [medicine] will find the advocates of evidence based medicine joining them at the barricades". Similarly, the claim that EBM pushes doctors to use only those treatments "research has proven [to] work" [1] bears no relation to anything found in the EBM literature. Quite the opposite, by incorporating decision analysis (see page 138 of Sackett et al's introductory book [3]), EBM provides an explicit framework for incorporation of therapies where evidence is incomplete.

    Questions:
    How much does empiricism weigh in EBM?
    Does "Research that is proven" trump empiricism clinically?
    :drinks
    Dennis
     
  2. I'd say quite a bit.

    And There is probably a formula along the lines of

    (Number of clinicians finding an unproven proposition empicically true * Length of time for which they have done so) / Known biasing factors (eg financial gain) = empicial weight Measured in alps*

    Yes. By definition. So long as the research is fully understood and not overextrapolated as it so often is.


    Regards
    Robert
    * As a measure of belief needed to move a mountain. 1000 millialps = 100 centialps = 1 alp = 0.0001 megaalps = 0.0000001 tera-alps.
     
  3. drsha

    drsha Banned

    I have made changes to a North Carolina University Slide (with permission) to try to educate those who are not well versed in EBM as to the two sides of the debate as I lecture. I would hope that the readers, by reading the slide would not know upon which side of the issue I speak but my bias is to the pro side,

    In addition,
    and most important. I have been a jerk on this site in order to anger and prod responses from my worthy colleagues and having gained enough foundational knowledge on many subjects after 1.6 years and having applied them to my practice and my theoretical work in order to organize and upgrade them, I have the strength and confidence to stop.

    I owe a debt of gratitude to The Arena for tolerating me as I found new ways "To Piss You Off" (quote Sam) and I hope that I have added some academic points into our discussions along the way.

    "There are many hypotheses in science which are wrong. That's perfectly all right; they're the aperture to finding out what's right. Science is a self-correcting process. To be accepted, new ideas must survive the most rigorous standards of evidence and scrutiny". Carl Sagan

    EBM Pro-Con.jpg

    Dennis
     
  4. David Smith

    David Smith Well-Known Member

    DrSha

    I generally agree with the statements in your table if we first define what is meant by evidence and proof

    Evidence:
    Evidence in its broadest sense includes everything that is used to determine or demonstrate the truth of an assertion. (wikipedia)

    that which tends to prove or disprove something (dictionary.com)

    sign or proof: something that gives a sign or proof of the existence or truth of something, or that helps somebody to…Encarta World English Dictionary

    And Proof:
    conclusive evidence: evidence or an argument that serves to establish a fact or the truth of something
    - test of something: a test or trial of something to establish whether it is true
    - state of having been proved: the quality or condition of having been proved (Encarta WED)

    conclusive evidence: evidence or an argument that serves to establish a fact or the truth of something
    - test of something: a test or trial of something to establish whether it is true
    - state of having been proved: the quality or condition of having been proved (Dictionary.com)

    The evidence or argument that compels the mind to accept an assertion as true. (The Free Dictionary.com)

    Evidence, Proof, Fact: are all means of determining or indicating the probability that a certain proposition is true. Evidence is used as an argument to indicate the probability that a certain proposition or group of propositions is true.

    Probability is, I believe, the most important factor to consider here. So this means that there is some basis upon which we will accept a statement as being true or false. This might be based on some intuitive concept of risk, i.e. what is the risk of accepting that a statement is true or proven


    The Scientific Method has given us a universally accepted method of assessing the probability of the truthfulness of a statement. This method is excellent for assessing probabilities of of the truthfulness of events that effect large groups but not so excellent at predicting the same effect on individuals.

    In the case that you are looking at DrSha, the clinician then needs to look at the universal event probability and assess how well it applies to the singular event.
    I.E. what is the probability that this universally observed result will occur in my patient, when the same change is applied?

    This then is the skill of the clinician i.e. to decide if the research is applicable or the research sample group is similar enough to his individual to be able to apply those results. Was the sample population similar? were the variables similar? was the change made similar? What was the clinical significance of the results? Does your individual sample contain any variables that were not included or allowed for in the research sample? How would this effect the results? This is ignoring the possibility that the research is not valid in the first place. Perhaps the fact that it is in a peer reviewed Journal might be good enough to accept this.

    If we assume that EBM means evidence gathered by research using the Scientific Method then, I think that Evidence Based Medicine should mean just that, i.e. based on the evidence available not Evidence Only Medicine i.e. using only the evidence available.

    If we assume that evidence means using all evidence and evidence is defined as that from research, experience, reason and maybe intuition, then I thinkl this is the most reasonable approach. Isn't this pretty much what we all do now in terms of the decisions made by an individual clinician for and individual patient?

    If on the other hand you are a practice or hospital manager or and you are looking for the best return for your money then this presents a whole different set of dilemmas. The manager considering a certain treatment does have large groups to compare with the large groups of a research study and could quite reasonably draw the conclusion that one specific treatment would give the best percentage outcome when compared to another single treatment. There is however, rarely any research available that compares the relative merits of variable variables, i.e. how different interventions used on different patients depending on the patient variable, changes the overall outcome for the whole group of patients.

    There are meta analyses but these usually only compare the difference between individual treatments to find which individual treatment was best. In fact this effectively is what the clinician might do when considering many research outcomes for the same problem and comparing how they each might apply to his patient. There is therefore scope for great skill and judgement by the clinician even tho he still uses EBM.

    The department manager usually has an entirely different goal to the individual clinician even tho he may think his aims are the same i.e. to cure as many people as possible (except that he may have certain caveat, like -within a certain budget and reducing the possibility of litigation)


    Cheers Dave
     
  5. [​IMG]

    The second negative is untrue. As you correctly say in the corresponding positive.

    The 4th negative is illogical (one cannot say that "there is not enough of it" is a negative of EBM. That's like saying that a meal tastes bad because its too small.)

    The last negative is presumptive. It takes a straw man caricature of a clinician with an exaggeratedly flawed understanding of EBM and blames EBM for this mythical clinicians faulty reasoning.

    Perhaps a better title for the slide would be EBM Myths / presumptions vs EBM reality.
     
  6. drsha

    drsha Banned

    States
    "The second negative is untrue. As you correctly say in the corresponding positive.

    The 4th negative is illogical (one cannot say that "there is not enough of it" is a negative of EBM. That's like saying that a meal tastes bad because its too small.)

    The last negative is presumptive. It takes a straw man caricature of a clinician with an exaggeratedly flawed understanding of EBM and blames EBM for this mythical clinicians faulty reasoning.

    Perhaps a better title for the slide would be EBM Myths / presumptions vs EBM reality".

    Dennis Replies:
    Your suggestion seems very productive. I will strongly consider making the change.

    Here is a definition of EBM off a british website blog.

    "What is evidence based medicine?

    Evidence based medicine is a methodological and systematic approach, which is of immense importance to the treatment of patients. It involves treatment processes being clinically tested, not only to discover what benefits such treatment has, but also to find what consequences there are of using such treatment. It is also the case that evidence based medicine should aim to discover what treatments are cost-effective, in order for medical physicians to offer the best treatment available, but at a good price.

    This is all done in controlled settings and through unbiased procedures. Without such research, the medical arena would not contain treatments that have been clinically tested to their limits, and also, medical professionals would not be so trusting of the care they give to their patients".

    I consider this an example of presumption #2 in action.

    Perhaps this posture drives a wedge between pure (perhaps older) clinicians and their desire to investigate EBM.
     
  7. David Smith

    David Smith Well-Known Member

    Robert, you nicely point out some of the faults in the individual arguments in the table, and that they do not fall into categories of negative or positive and even if they did those terms, in this case, are relative to the original point of view taken and become meaningless in themselves.

    Can we allow some licence here though and just take the overall gist, which as I understand it is that DrSha takes the view that;

    EBM is useful when applied correctly but many people misunderstand or misapply EBM. This then lead DrSha to ask, if then EBM is useful " How much does empiricism weigh in EBM?" and "Does "Research that is proven" trump empiricism clinically?"


    Don't you think that both these questions are really asking how do we know what we know, which is of course the basis of epistimology. Empirical means gaining knowledge through experience of the senses i.e. testable observation. The scientific method demands that evidence is empirical, and so the first question - " How much does empiricism weigh in EBM?" might be answered, completely 100%


    Therefore Empirical is the adjective that describes Evidence, The noun, Empiricism, can be slightly different from the adjective empirical. In that, philosophically speaking, Empiricism states that ALL knowledge is gained through the senses. Encarta dictionary also defines Empiricism in medical terms as - evidence based on practical experience and not on theory or scientific proof.

    So there seems there could be some confusion in how we apply the terms we are discussing, can we define EBM as scientific proof and universal, qualified by research and Empirical evidence as individual experience and singular and without formal qualification.
    In this case the question "How much does empiricism weigh in EBM?" would ultimately be - nothing at all 0%.

    The answer to the second question "Does "Research that is proven" trump empiricism clinically?" has no straightforward answer, since it depends on your risk assessment of accepting the truthfulness either type of evidence in terms of a specific patient.

    If I stick a pin in a patient’s foot and he shouts ouch I know with a very high degree of probability that it hurt and would hurt if I did it again. This is empirical evidence (of the 3rd definition) and is quite convincing, I do not need a research project to increase my confidence.

    On the other hand if I wanted to know if the wound caused by the unsterilized pin might become infected, then research evidence (EBM) from a large group would be far more convincing than my one example, unless of course I was not entirely objective and was convinced that my opinion based on my own experience had much more worth than any other.

    Good Discussion topic

    Cheers Dave
     
  8. I am enjoying the discussion on evidence based medicine. For myself, I am torn between both sides of the argument. However, in my searching through the literature, and having now been in clinical practice for a quarter century, I found an article that pretty much sums up my concerns about evidence based medicine.

    Cohen AM, Hersh WR. Criticisms of evidence-based medicine. Evid Based Cardiovasc Med. 2004 Sep;8(3):197-8.
     

    Attached Files:

  9. Since he's in the thread title perhaps we could consider the most generally accepted definition from sackett himself

    for me the key here is the word integration. Ebm is inclusive of individual expertise not alternative to it. But to intergrate, the two must compliment one another. If the individuals opinion is contrary to available evidence, or if there is no supporting evidence at all then the two cannot be intergrated. If, however, they individual expertise fits with such evidence does exist then it can.

    IMO.
     
  10. Robert:

    Of all the therapies you provide to your patients, including the obvious multiple orthosis modifications you make for your patients, what percentage of these many types of therapies, would you estimate, to be supported by Grade A (levels 1A-1C) evidence?
     
  11. Not a lot. For obvious reasons (like the n=1 embuggerance) that sort of evidence is hard to come by.

    However.

    As per sacketts definition I like to think that it is all compatible with known factors.

    None of it relies on concepts outside of scientific principles.

    All of it is based mechanical concepts which have been demostrated or which can be reproduced.

    All of it is open to challenge and modification if as and when our understanding improves.

    For example, I used to beleive that I had a good chance of slowing/ preventing HAV in kids. Now, after a few yearscand the kilmartin study, I don't and my practice, and the claims I make to patients reflect this. Thus my personal experience was intergrated with external study data. EBM, or so I like to beleive.
     
  12. Robert:

    I would like to also believe that, ideally, Sackett's evidence based medicine (EBM) is a wonderful thing for physicians and their patients. However, in real life, since so much of what I do in practice, including custom foot orthoses and foot surgery, can not be practically researched using experimental controls that the patient is blinded to, then I have found that those that want to discredit the effectiveness of foot orthoses or foot surgery use EBM concepts in order to minimize the importance of much of what I can do for my patients.

    In addition, since so many of the treatments that I provide to patients have not been (and may never be) researched at higher quality levels during my remaining life as a clinician, due to lack of funding sources for such studies, then I have not found that EBM has done much positive for me or my patients, other than giving insurance companies another reason to deny valuable treatments to my patients.

    Therefore, can someone give me some good examples of how Sackett's EBM has improved the podiatric treatments to their patients (and improved the lives of these patients) that suffer from foot and lower extremity pain and disability? Maybe I am being overly negative, but from what I have seen so far, EBM is a good idea that has had little positive effect on my patients' foot health and is increasingly being used, negatively, to deny otherwise effective treatments that don't have high level research evidence to support their continued use.
     
  13. drsha

    drsha Banned

    Dr. Kirby responded to Functional Foot Typing in 2008 by stating “We are quite far along, Dennis, in using engineering and biomechanics terminology to understand how the human foot works. I have spent the last quarter century and, with the help of many of my colleagues who also participate on this international podiatric medical forum, have endeavored to advance the sophistication of podiatric biomechanics away from the Root model and toward a model that is based on strict Newtonian principles using currently accepted biomechanics and engineering terminology. Unfortunately, I see your model as a throwback to the Root model that I have worked so hard to get the profession to move away from for the past quarter century. Therefore, I simply don't see much benefit taking podiatrists back a step or two in sophistication, when they should rather be keeping more in step with the mainstream international biomechanics community and their prolific research on foot and lower extremity function”.
    His goal is well stated: to move biomechanics toward a model based on strict Newtonian principles using current accepted engineering terminology (accepted by whom amd with what EBM?).
    For me, it follows that after making the terminology conversion, secondarily, he will do as much as he can to benefit mankind with diagnosis and treatment of pedal biomechanical pathology and its impact on humanity.

    Now, yesterday, he argues as if Shavelson, Dananberg, Glaser, etc. that “Maybe I am being overly negative, but from what I have seen so far, EBM is a good idea that has had little positive effect on my patients' foot health and is increasingly being used, negatively, to deny otherwise effective treatments that don't have high level research evidence to support their continued use”.

    So in a quarter of a century, Kevin has not been able to produce any Level A-1/A-C evidence related to his biomechanics and neither have the rest of you over any schools of biomechanics as admitted by Robert as he states “Not a lot”. Level 1/A-C evidence has proved STJ Neutral custom casted devices no better than OTC Devices, STJ Neutral theory to be less than scientific with its measuring, forefoot to rearfoot relationship, its 1-2 ratio for frontal plane rearfoot diagnosis, etc. We must use this valuable EBM and move forward. Glaser is selling Whitman braces by proving Root vestigial in 70 of his 90 slides and Kevin asks “Is Root Dying” to justify us examining a subtalar joint axis that will remain impossible to examine for level 1 EBM for another 25 years.

    In answer to Kevin’s question about EBM and podiatry, when it comes to diabetes, wound care, arthritis, dermatopathology, pharmacology and certain aspects of surgery (wound healing, instrumentation and tech advances), EBM is alive and working well as an important practical and teaching tool. It just does not work well with biomechanics. It works well to prove the need for a new normal science but not for developing EBM with clinical relevance.

    Robert unscientifically states that his clinical work is valid and state of the art because:
    None of it relies on concepts outside of scientific principles.

    It’s based on mechanical concepts which have been demonstrated or which can be reproduced.

    All of it is open to challenge and modification if as and when our understanding improves.


    When I stated almost 1.5 years ago that “Until convinced otherwise I believe passionately that I can help those who are obese, those who have inherited faulty foot mechanics, children, athletes, etc. better than you can”, Ian replied and was applauded that “I wasn't aware any of us did this job in competition with each other - surely we all do it with the patients interests in mind ahead of our own egos? If yourself and another clinician are both applying different paradigms to patients, yet both managing to get patients symptom free and back to their own individual qualities of life/goals how can you claim one clinician is 'better' than the other? By using EBM is my answer!

    My comment remains even stronger if you use Roberts Rules of Practice to treat biomechanically. Obviously, there is a huge Bell Curve of orthotic making separating all its clinicians and some will have better outcomes than others. Scientific competition is what drives scientific growth.

    EBM takes large populations of subjects and examines a clinical question that arises between a clinician and one (or a small number of) patient (s). It then uses the best available evidence that drives statistics and treatment paradigms as it relates to that large population and decides how strongly that information answers the one on one question at hand.

    The biomechanical dilemma that studies of large populations of feet does not lead to valid research with an acceptable rate of error has not been answered by converting to Newtonian terminology or Kevin's self validated thought that only those converting to Newtonian language are going forward. We need something additionally when it comes to EBM.

    Why?
    Because there are no normal feet available for study or for comparison and feet vary so greatly in type and function as to skew the evidence when studying the current large groups being selected for research

    I maintain that Root and Kirby’s original work applies to the flexible rearfoot foot types only. Dananberg’s brilliant work applies to the flexible forefoot foot types only and Glaser’s, unfortunately, does not apply directly to any foot types. I maintain that when a large population is functionally foot typed, focused research on a flexible rearfoot type population will validate Kevin’s work and research on a flexible forefoot type population will further validate Howard’s work and no valid research will come up for Dr. Glaser's MASS.
    Furthermore, I insist that the rigid rearfoot, rigid forefoot foot type must be left out of most of our research and be studied as its own entity (as well as the flat/flat foot types) since these feet do not STJ frontal plane pronate, they have no functional hallux limitus and their vaults are rigid enabling them to pervert outcomes significantly when included for evidentiary study.

    Simply put, profiling all feet into their FFT’s for purposes of research and treatment opens up a level of EBM that has to now, eluded passionate practitioners of biomechanics.

    If any of you know the biblical story of the Tower of Babel, I think there is an analogy that we are living in The Tower of Biomechanics and rather than spread us around the world speaking different languages foreign to others, we seek a biomechanical world where all schools can be examined and scrutinized and selectively produce the evidence that until now, remains a dream.

    http://www.podiatry.com/ezines/?pub_year=2009&section_id=51#ezine483

    DrSha
     
  14. We now return you to your regularly programmed drivel. What a shame. For a few days you were posting like an inquiring mind rather than an egotistical and ignorant salesman.

    When did I say my work was state of the art? (a clue, I didn't, you just "made that up")
    When did I state my work was valid? It is, mind, but I never said that.

    What is unscientific about those three statements?

    You insist. Oh well if you INSIST... EVERYONE STOP WHAT YOU'RE DOING, DENNIS INSISTS!

    Dennis, the reason you can't debate this stuff using standard terminology is that as the above statement, and may others you've made indicate (I liked the one about a momentary force) You don't understand it.What is to "not frontal plane pronate"? If an undergrad said that I'd go shout at their Professors.

    B*****ks. Have you actually read any of the studies you allude to? They prove no such thing.

    You also seem to have little understanding of EBM.
    So just to be clear, your EBM is that you are a legend in your own experience but that is the only indication you have. That's not EBM.

    I'm trying to remember the pithy epithet Simon gave you a while back. Began with T I think...
     
  15. Hey Kevin.
    I really don't think things are that bleak. As you say, direct X prescription works for Y pathology type evidence is thin on the ground. But that's not the only way evidence works IMO. Although if you wanted such an example the prevelence of literature on lateral wedging for medial compressive Knee pain, (and your snoopy picture) have changed my prescribing habits to the benefit of my patients.)

    However. There are a few fundamentals of mechanical care which have been accepted and used for centuries. Things like reducing demand on damaged structures being helpful. There are something like 800 muscles in the human body. If you know that one which is damaged or inflamed is helped by reduced demand you don't have to do the same study 800 times to call such treatment evidence based.

    Ditto ligaments. Ditto inflamed tissue of almost any type.

    But how do we get from wanting to reduce demand in damaged tissue to a piece of bent plastic? We need to know what each of the structures does, and how.

    That's where a mechanical understanding of Biomechanics comes in.

    As you know better than me we've spent the last 50+ years refining this understanding. From gross and flawed anatomical observations like "flat feet" and Kapanji's 3 arch model, through tautology, and beyond.

    The process of using engineering and newtonian principles, (proven by physicists for centuries) to bridge the gap between our day to day practice and the known biological principles of treating mechanical injuries is by its very nature, evidence based.

    I doubt it will ever be complete. But the better we get at it, the better we will be as clinicians.

    Again (and always) IMO, EBM is not about finding out through a double blind RCT that paracetamol is good for headaches, and through another for knee pain, and through another for elbow pain etc etc. Its about understanding how it works, and then understanding how WE work, and then prescribing based on that understanding. Thats still EBM, even if I can't find a study to show that paracetamol helps for putting a screw in your thumb (as I did recently).

    The antithesis of EBM is treatment regimes which start with a treatment, then work back to the cause, constructing a model of understanding the pathology based on the treatment available at hand. Its easily recognised by people who diagnose pathology in the paradigm and terminology of the treatment. Your headache is caused by an imbalance of chi and such.

    As you know, I wrote an article recently to applaud the simple process of keeping assessment in the order "diagnosis -> treatment". When the treatment, or the assessment protocol starts informing the diagnosis, you're in trouble.

    Cheers
    Robert
     
  16. Dennis:

    It is rants like the one you made above, where you turn a good academic topic on evidence based medicine into an advertisement for your functional foot typing, that has made me not even want to discuss things with you publicly here on Podiatry Arena. I am certain that many others may feel the same as I do in this regard. If you could simply stick to the topic at least once here on Podiatry Arena, and not continually and incessantly squeeze in a plug for something you have patented or marketed on the internet, then maybe others would be more willing to discuss things with you in public. It is getting very old.
     
  17. Robert:

    As you know, I have no problems with using sound mechanical principles to guide my treatment process with mechanical foot therapy and have been trying over the past quarter century to direct podiatric biomechanics to being based more on Newtonian mechanics and less on unsound mechanical premises.

    When I first wrote about the medial heel skive in 1992, for example, what level of evidence would this in the "pyramid of evidence"? For example, if I were to propose that a medial heel skive orthosis could theoretically reduce the pain of posterior tibial dysunction and I saw that happen 100 times over a year in 100% of my patients, where would that be in the Sackett's evidence based medicine (EBM) ranking? From my understanding, this mechanically-based treatment plan that worked so well in my hands would be at the bottom of the EBM pile. And, to many EBM experts, the medial heel skive orthosis would therefore be not recommended as a useful treatment since there had been no carefully controlled randomized trials and therefore, would hardly be worth considering as a valid treatment. Am I incorrect in this assumption?

    Often, when discussing the problems with using EBM as a way to decide the reality of the effectiveness of our treatments for patients, I use the analogy of how many times do you need to see that when it rains, the ground becomes wet? I have observed, many times, that when it rains, the ground becomes wet. However, to my knowledge, there are no carefully controlled randomized trials published in the peer-reviewed literature that support my hypothesis that when it rains the ground becomes wet.

    In other words, even though I think I understand the concepts of EBM, I place more value on my knowledge of physics, physiology and anatomy along my powers of observation as an experienced clinician than I do on any research but, to many EBM experts, these clinical skills and knowlege that I have acquired over a lifetime are at the lowest level of evidence. Is this really the best system for our patients in order to bring them the best quality medicine?
     
  18. drsha

    drsha Banned

    Kevin:
    I felt that one good rant deserved another.

    Robert:

    My last post was opinionated (as are yours) but to call it an advert shows your inability to argue the points. I am entitled to discuss my work as you discuss yours.

    I read other threads on The Arena and I am sorry that british DPM's working just or harder than I for your gov't earn 30,000 pounds annually (or 97,000 pounds after 19 years)and we earn more as a group in America. I'm sorry that you feel that the fact that I have patented and trademarked makes my work unappealing and that podiatry should not have a capitalistic bone to expose. I have admitted that I do.

    I thought we were getting closer to The Arena scrutinizing my work and not the fact that I want my grandchildren to profit from it if it has value.

    Your snide comments don't change the fact that your statement was not scientific (why don't you argue against it logically as you do mine). If I was a professor, I would tell my students to not pay much attention to someone with unproven, self validated practical dictums as you claim to have who values his opinion of himself as lofty as you do yours.

    Would cavus feet skew scientific studies?

    I am sorry that when I attempt to expose the flaws in your arguments and statements as you do mine, I become an egotist and you become the judge and jury.

    I'll watch this thread from afar for awhile as I agree with you two that it is a good one and I don't want to be a distraction. Please remember who started it.

    DrSha
     
  19. Oh feel free to join in dennis, but if you don't want to be a distraction, try to keep on topic. That's ebm, not why you are a superior clinician. Saying that you are better than everyone else because of ebm, then not describing how does not give us much to discuss. Also, misquoting people is rude and will tend to derive a response as such.

    It's annoying that every time you post on a thread it always comes around to how your way is best almost immediately. Sorry, but it Does smack of self promotion rather.

    However. Your point about different foot types and their affect on outcome studies is somewhat pertinant. The problem we always have is that if we take a patient group by pathology (say heel pain) we cannot apply the same treatment to all because the pathology will have potentially different mechanical causes.

    Testing by fft (like excluding cavus feet as you suggest) would work for you and reflect your practice... But it would ONLY work for you and whoever uses your paradigm. And very few people use it. Although it would validate you claims. Please feel free to do such a study, but I doubt you'll be killed in the crush of researchers desparate to do a study on your behalf into a concept which has been around for over a decade.

    So insist away, but unless you can convince people that your model has merit, nobody is likely to adopt your paradigm into their research.
     
  20. David Smith

    David Smith Well-Known Member

    DrSha

    I wrote
    I'm not trying to be rude here but can you not see how this statement might apply to you?

    Kevin, Robert and many others use a method of evidence gathering that uses universal statements, extrapolated from a generally accepted axioms, that can be applied to the singular problem by the way of logical reasoning. So while there may not be direct research that is applicable to the singular problem, deductive reasoning based on generally accepted concepts or axioms does allow one to apply universal results of scientific research to the singular problem. This in my opinion is how evidence based medicine works best.

    On the other hand you gather your evidence from a poorly accepted axiom with singular statements and apply it to the singular problem.

    This does not ultimately mean you are wrong, just the probability that you are wrong is is quite high and the risk associated with accepting your proposals as true is also very high.

    To expand on this:

    Kevin uses the axiom or concept of mechanics to apply to his foot treatment model. By the use of logical reason he can apply the research and the generally accepted trruths (axioms) such as Gravity and leverage and force ect. These are axioms with universal statements (researched results on many samples) that are very hard to deny and have little risk in accepting.

    You DrSha,on the other hand, have adopted the Foot Typing System, which is not a generally accepted truth and your evidence is based on how you accept or interpret the results your own work, these then are singular statements applied to the singular problem and then you propose or even insist that these results should be accepted as universal statements just because of your own opinion.

    The former method uses truths from inductive reasoning to validate deductive reasoning that is extrapolated to the singular problem.

    The latter uses truths from intuitive reasoning to validate deductive reasoning that is extrapolated to the singular problem.

    You say, I believe that this system is correct (your initial intuitive statement and your axiom), you use that system (or axiom) as the basis for your logical reasoning and apply that reasoning to your patient.

    How confident can a person be that the initial statement (axiom) was true when it was only the product of personal intuition?

    I would say that the confidence in accepting the initial truthfulness should be very low. Any confidence in accepting statements built on that axiom therefore should be equally low.

    To reiterate - Unless of course one was not entirely objective and was convinced that one's opinion based on one's own experience had much more worth than any other.

    Does this make any sense to you DrSha, I'm not saying you are wrong just the probability that you are right is very low by the terms of accepting your evidence that I have outlined above.

    Perhaps you have a different way of validating evidence with low probability and high risk that enables confident acceptance of it. If so could you explain?

    All the best Dave Smith
     
  21. Waste of time, Dave. I thought this statement was most instructive.....
    I would suggest that 'exploit' may be more accurate that 'expose' given his previous history - not quite in the same league as Rothbart et al but certainly playing the same game - i.e. deliberately misleading and deceiving patients and colleagues for their own financial gain. Shameful.

    All the best

    Mark
     
  22. Found it.

    http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=88248&postcount=156

    Possibly a little harsh. Call me a naive romantic who always sees the best in people but I don't think Dennis is acting cynically. I believe he believes what he's saying. Trouble is, you don't understand what you don't understand. If the realm of newtonian biomechanics was as Dennis talks about it (pronation not in the frontal plane for eg) then his model makes sense... kinda.

    I think the sin is one of omission and possibly ignorance rather then deliberate deception. Paynes (first?) law explains the passion with which the beliefs are promoted.

    But perhaps I'm too kind.

    Regards
    Robert
     
  23. That's the trouble with belief systems and those who subscribe to them even in the case of overwhelming evidence to the contrary; they are beyond reasoned argument. Ergo; I believe, thus it must be so. Try visiting your local baptist, muslim, catholic, protestant etc etc church or mosque on their day of worship and say "show me one piece of evidence that there is a all seeing all knowing diety and he or she does exactly what your faith say he or she does" and you get the same response as Dennis offers when discussing biomechanics and foot function i.e "I'm right and you're wrong, because I say so." I just hope he doesn't roger boys on his days off. http://www.timesonline.co.uk/tol/comment/faith/article7065824.ece
     
  24. Mark:

    Why do you think, Mark, that some of the greatest scientists of all time, such as Isaac Newton and Albert Einstein, believed in God? Were they delusional as you imply that all baptists, muslims, catholics and protestants are in your statement above. Were these genius scientists wrong and you right?
     
  25. David Smith

    David Smith Well-Known Member

    Mark

    :eek:Why I oughtta!?!***$£!*:boxing:
     
  26. Well, I guess you need to ask them, if you ever get the chance, Kevin. But perhaps they were just ordinary human beings with the same frailties and failings as the rest of us and frightened of death and the prospect that there is nothing else in the after. If religion gives them or you or anyone else comfort in that respect, that's fine by me. But, it is a belief or a hope - nothing else. As you might say to Dennis - show me the evidence to the contrary!

    All the best

    Mark
     
  27. David Smith

    David Smith Well-Known Member

    Mark

    That's the whole point - Anyway lets not go there its diverging from the point of this thread

    Regards Dave
     
  28. OOOOOO religion. A gnats off topic but still.

    Actually I'd say "Mark what the hell are you doing all the way down here?!" Then offer you to come meet the family.

    But all joking aside, there is a not invalid point there. We are all permitted to have unsupported beliefs. Nothing wrong there. I suspect, Mark, that you are quite content for Dave and I to go take solace in our unsupported beliefs.

    But if we rolled up in your drinking hole and started shouting the odds about how our unsupported beliefs made us better people than you, how you would be letting your patients down if you didn't adopt them too, and suggesting that you were only not accepting our beliefs because you were too stubborn / stupid, or that the only reason you would would not accept what we said was that you didn't like us....

    You'd give us a slap! And you'd be right to do so. Well, actually you'd probably just give me a slap cos Dave is a well hard MMA instructor whereas I'd generally just curl up in a foetal ball while you kick me in the back.


    Regards
    Robert

    PS as a BTW, since einstein was mentioned here is what Stephen Hawking had to say about God
    So there.;)
     
  29. Is it? The thread is about evidence based practice and, as observed by Robert, views of a modality of practice that appears to have no evidence and is based solely on belief. I would argue that is exactly the same as debating whether or not there is a diety and whether any one religion is better in its doctrine than another. I guess with religion, especially those who subscribe to such practice, is that the stakes are much higher than mere pedal dysfunction and so the argument can be (and usually is) more strident. But, just like the arguments tabled by Rothbart, Shavelson et al., it doesn't mean it is right just because you repeat it often enough or shout it louder than the last time. You might argue that there is no basis for functional foot typing or proprioceptive insole as a treatment for fertility or reducing diabetic amputations, but equally, applying the same principles to religion and an afterlife, doesn't exactly stand the entire basis of religious belief in a very strong position, does it?

    Mark
     
  30. Apples and oranges.

    FFT, PCI's and babies from insoles are models for mechanical function. Mechanical function is an objective temporal reality which can be tested, investigated and researched, have physical principles applied to them etc. A mechanical model must conform to what we know about the laws of physics (which canna be changed as per the star trek song).

    Religion, by contrast, is (for me) a simplified model of something which is supernatural and ineffable by definition. Therefore any religion can no more be shown to be fallacious than it can be proved to be true because it has no objective yardstick to be measured against.

    Thats IMO anyway.
     
  31. "And if you shout, I'll only hear you." U2 stay (faraway, so close) :morning:
     
  32. You can believe in anything you like Robert - no problem with that - and as you observe, the problems only arise when you try and force others to accept your point of view against their will or wishes, contrary to their own beliefs. For me, however, religion is more insidious, given that we allow children to be indoctrinated from an early age into that particular system of belief, without a shred of evidence to support it. I wonder what would happen to some people if or when an alien intelligent life form pays our little planet a visit and tells us religion and god is pure superstition and nothing more than a fabrication of our own frightened imagination..... Good for Stephen Hawkings - would you like me to quote some Richard Dawkins or AC Grayling? ;)
     
  33. Are they cosmologists;).

    We indoctrinate children into lots of things with no evidence. Some (like the easter bunny) they later learn are spurious. Others (like Father Christmas) are of course real, irrespective of the lack of evidence.

    But your central point is a good one. Religion works for me. FFT works for Dennis. But I'd be a fool to try to convince you my religion was real on the basis of a logical argument... because that is not the basis of it. Like most people I started with my A Priori core belief (faith if you will) then built logical arguments around it to try to shore it up. Very, very very few people come to religion as the end point of a logical investigative process. It generally happens the other way around. I've only met one person who developed their theology through a painstaking investigative process (and I'm pretty sure they just did it that way to be contrary ;))

    Apologetics is a very different art to evangelicalism. One defends the props of belief, the other tries to implant an emotional and irrational seed of belief. That, perhaps, is where Dennis is failing. He's defending the props (badly). But we will no more change his core belief by pointing out the flaws in the props than he will every convince us of the core. He's an apologist. To win converts he needs to try evangelicalism.

    If you have an audience who WANTS to believe something, who perhaps is not confident of the harder school of biomechanics, or who is too lazy to seek the harder answers and wants simply a shake and bake, works-out-the-box system of biomechanics, well then hallelujah brother we have a convert. Who will defend their core belief to the death because they want and need it to be true. Who decided to buy said belief lock stock and barrel because they wanted biomechanics to be that simple. And against whom logical argument will be futile because it attacks the props and not the core.

    Cheers
    Pastor Bob;)
     
  34. PS. That last paragraph was not a suggestion Dennis!!!

    Oh hell, what have I done?!?!:eek:
     
  35. Isn't that the whole point? The key word being "works"...
     
  36. That's what we'd all like!

    But only IF it works of course.

    And I'm pretty sure a lot of the out the box models have bits missing.
     
  37. Which brings us back to the topic of evidence based medicine and specifically, WHY evidence is given to a hierarchy.
     
  38. Evidence, in its hierarchy is good.

    This, as Dave put it so beautifully, is also great.
     
  39. Found the song for the FFT threads.

    Bleed it out, Linkin park

     
  40. Yes, I read that. What is the best way to test whether the extrapolation from the axiom is valid? Can you explain to me why a blinded randomised controlled trial scores higher in the hierarchy than a single case study?
     
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