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EBM Terrorism

Discussion in 'General Issues and Discussion Forum' started by drsha, Apr 15, 2009.

  1. drsha

    drsha Banned


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    Just thought this post on another site by Allan Jacobs DPM would be of interest, especially to students who still question their respected leaders.

    "At the recently concluded meeting of the American Professional Wound Care Association, a European vascular surgeon was critiqued for "lack of evidence-based medical proof" that osteomyelitis could be managed by antibiotics alone. The speaker opined that "we need to end this obsession with EBM. He noted that 95% of what we do in medicine is not supported by EBM. He did not suggest any lack of value to EBM, but rather that our clinical experience, clinical sense, and clinical judgment ought not be devalued. He called for an end to "EBM terrorism." This was met with applause from the audience.

    The recent commentary regarding Aldara is such an example. Many of us have had successful outcomes with Aldara for the treatment of verruca. Every day, we provide successful services in our offices without an RCT supporting the therapy provided.

    I appreciate the commentary by such accomplished academics as Dr's Udell, Turlik, and others. However, let's get real about the science and ART of medicine. The lack of an RCT does not and should not trump the utilization of diagnostic or therapeutic modalities which the practitioner knows through experience or believes by judgment would be helpful to a patient. If we limit our services to only EBM/RCT established therapies, we would have little to offer our patients from day-to-day. Experience, judgment, opinions, are also a form of EBM. Let us not forget the ART of medicine.

    This echoes the sentiments which I have posted on this site.
    :drinks
    Dennis
     
  2. DaVinci

    DaVinci Well-Known Member

    In my experience and opinion, the loudest critics of evidence based medicine are those who clearly either do not know what evidence based medicine is or characterise it as something that it is not.

    The most widely used definition of EBM is that of Sackett:
    "Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice...Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough"

    That definition of evidence based medicine includes the "art", so I do not see what the problem is.
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. DAVOhorn

    DAVOhorn Well-Known Member

    Dear Dennis,

    I agree mostly with what you have said.

    However many medicaments have been withdrawn over the years due to EBM showing that there nay be problems.

    When i was a kid the school nurse had a passion for :

    Mercurichrome
    Gentian Violet
    And the green one the name of which i forgot.

    Today we only really use Povidone Iodine as a general broad spectrum anti septic.

    A lot of the ART of Medicine is based upon good patient management and trust, could this be the PLACEBO EFFECT at work????

    My other favourite today amongst Professionals in any discipline, in fact this staement was on the radio tonight, is AND WHICH PEER ACCEPTED SCIENTIFIC JOURNAL WAS YOUR PAPER ON THIS SUBJECT PUBLISHED?

    The power of suggestion i would suggest is a very powerful tool that we use everyday in our practice.

    We can use it to our advantage and to the patients advantage / disadvantage as we feel so inclined.

    A simple:

    How are you today?

    or

    It is a beautiful day to day isnt it?

    Will elicit completely different responses and will thus set the scene for further discussion with the patient.

    So is EBM just an additional tool with which we use to improve the quality of practice.

    My bugbear is the patient who Google's what ever is their apparent symptom/s and already has made a judgement and heaven help you if you offer a different idea. They already have their answer and seek from you the reward of agreeing with them.

    This is fun subject with i feel no definitive correct answer.

    This is where our knowledge and clinical judgement comes into play, and upon which our apparent skill will be judged by the patient.

    Look up the animosity with Caesarean Births and home NATURAL birth argument on the internet.

    Here in aus we recently had a tragedy where a Very Keen advocate/supporter of home births, and is very anti Hospital intervention, lost her child during a home water birth.

    I believe in the States Cameron Diaz has a very vociferous site regarding Natural Home Births and this is having massive impact amongst the Americam population.

    So this might be a very relevant area for EBM to be utilised.

    We in the west have sophisticated health and social care systems that ensure a low mortality rate and in 3rd world countries Women will walk for days to access a hospital to improve the chances of a safe birth in a safe controlled environment.

    This is an intersting conundrum is it not?

    regards David
     
  5. drsha

    drsha Banned

    David:
    Marvin Steinberg DPM's Gentian Violet costs about $4 a bottle and has no patent so it is not promoted.

    it is antifungal
    antiviral
    antibacterial
    antimonilial and
    astringent (how many A's in what you currently use?

    making it a pergect paint for wounds to this day.

    I have built my wound healing career on gentian violet and a roll of foam for balancing.

    BTW: cresal green (mostly russian--Kiev) is the green stuff
    Cheers
    Dennis
     
  6. :good::drinks

    Indeed the same could be said of many on this forum. Some come seeking knowledge. Some come offering it and holding an open mind to the discussion thereof. Others come convinced they have the answer and seek only the blessing of the community!


    Agreed! I read a piece in the local paper recently by someone who stated that "before chaos theory, scientists carried out experiments to find the results they wanted to find":bang:. People should learn what the scientific method involves before they critique it!

    As in
    To be fair, he may have been quoted out of context but this is clearly fallacious.

    The person who has taught me the most about EBM is our own Dave Smith. He introduced me the concept that evidence comes in two flavours, inductive and deductive. Inductive evidence is what people tend to assume when they talk about EBM. For example, if i drop a pen 100 times and it falls 100 times I have inductive evidence that it will fall. Now, consider a pencil. Based on that evidence do I have Inductive evidence that pencil will fall in the same way as the pen? No. I've not tested it directly. However I can observe that it is the same size, approximate mass, is in the same gravitational field and is held in the same way as the pen and thus DEDUCE that it will fall. I have deductive evidence it will fall based on the pen experiment.

    In the same way I don't know of any Inductive evidence that a heel raise would help a severs patient. However I know the mechanism of the pathology, the causal force, and enough about how the foot functions to DEDUCE that the heel raise will reduce that force. I could therefor reasonable state that I could point to deductive evidence that a heel raise should help. This is where a lot of "conventional" medicine differs from "alternative". Reflexology, for eg, could point only to Inductive evidence (if such existed) as there is no deductive mechanism for action. The best it can do is anecdotal. And as we know the plural of anecdote is anecdoteS NOT data.


    Of course both mechanisms of evidence can be flawed. Inductive evidence is prone to error, bias and contamination of data. Deductive evidence can be taken to a degree where though coherent, the chain breaks down (as in Prof Brian and his infertility cure). But both deserve consideration.

    This would be worth considering the next time any says that SALRE has no evidence to back it up. There IS. Its in physics. What it tells us about how the foot works constitutes deductive evidence based on what we know of physics and what we know of the joints of the foot.

    Fascinating stuff.

    Kind regards
    Robert
     
  7. David Smith

    David Smith Well-Known Member

    Ah! a mention in dispatches, Top hole sir! what

    LoL Dave
     
  8. David Smith

    David Smith Well-Known Member

    Robert

    Here's an interesting point of discussion.

    Even tho I may have said it previously, I not sure that strictly speaking you can use the term deductive or inductive evidence. Inductive and deductive reasoning or logic are how we present the evidence to support or test our case. Evidence is a sign of the existence of a truth and we can construct our argument by using these signs in a deductive or inductive manner.

    A third type of reasoning, Abductive, does not require evidence or a sign of the existence of a truth. This is a logical fallacy that uses the post hoc ergo propter hoc argument i.e. This happened after that therefore this is a consequence of that. We cannot call this Abductive evidence since there was no sign of the existence of truth for that event conclusion. (correlation does not equal causation)

    Inductive reasoning; uses the singular statement, or in other words the truth of many singular events, to predict the universal statement.

    Deductive reasoning; uses the Universal statement, or truth of a (or several) universally accepted axiom(s) to predict the singular statement.

    Abductive reasoning; uses only intuition and past personal experience to explain an event and has no evidence in the formal sense.

    I.E.Intuition = Unconscious thought process that produces rapid, uninferred knowledge or solution. It is not analytic in the sense that it does not deliberately look for cause-and-effect (causal) relationships, intuition is not mere guesswork. Instead, it draws on previously acquired experiences and information and directly apprehends a totality. Intuition can be visionary or delusionary, uncannily correct or horrendously wrong in its conclusions (ref:business dictionary.com)

    Logically however, deductive and inductive arguments are valid, whereas the abductive argument, although it may be correct in its conclusion, is invalid in its construction and therefore wholly unreliable.

    Gotta go for now

    like to hear your thoughts

    All the best Dave:drinks
     
  9. Frederick George

    Frederick George Active Member

    Interesting stuff.

    Back to EBM, how many of us have been sitting through lengthy biomechanicist research presentations based on "models" developed by deductive reasoning, necessarily simplified to the point of uselessness. I supposed the authority of having academics gives a sense of independent authenticity and credibility to our podiatry seminars, but is it true and does it work?

    EBM applies where little or no individual expertise is required. Drug trials are an example. Statistics work there.

    Biomechanics and surgery results are determined by the judgement and skill of the particular practitioner applied to the individual patient.

    Do orthotics work for arch pain? What kind of orthotics? What prescription? What casting technique by whom? What is the arch pain Dx, foot type, age . . .?

    All of these individual variables can't be adjusted for with fudge factors.

    The data becomes meaningless.

    So, certainly EBM should be looked at, but in our hands-on type of medicine, it's usefulness is limited. We are all creative practitioners. That's why we call it practice.

    Cheers


    Imagination is more important than knowledge.

    Albert Einstein
     
  10. David Smith

    David Smith Well-Known Member

    Fredrick

    You wrote
    All truths are the product of a belief system of a group, usually a large group. These groups of people usually have a hierarchical system whereby the superiors are the 'keepers of the truth' as it were.

    Do you mean that or do you mean EBM requires little expert or intimate knowledge of a certain individual?

    Certainly EBM is often characterised as inductive evidence (yes! I know, but it's a convenient term :eek:) and so by its nature evidence from the singular experiment is inferred to the universal experience. Deductive reasoning, however, is also a valid measure of the reasonableness of EBM.

    It is well known that inductive evidence can, by the laws of probability, only be reliably applied to groups or populations and that the singular entity may fall outside the statistics of the experimental experience. This is fine when using a standardised treatment to get the optimum cost versus outcome ratio. As I think you have pointed out this may or may not be the best treatment for a certain individual of interest.

    However it is then down to the judgement of the clinician as to which treatment modality to use, he can consider EBM modes, in their widest terms both inductive and deductive, or he or she can consider using a treatment mode that is based purely on their own experience and patient presentation and come to a conclusion using abductive reasoning. How reasonable this is an unknown factor. How would you decide if your child was offered two drug treatments, 1) tested by Dr A's intuition on 25 patients who mostly seemed to do OK or 2) one tested by 10,000 doctors over 10 years and 20 million patients, where they find good outcomes with low risk for most people but occasionally there are disastrous or useless results.

    Yes but how did the practitioner acquire these skills and the ability to make such judgements? They will usually rely on a belief system of a group, that group may be small and I would say that as the group of individuals become smaller (relative to the population of individuals within a certain discipline) the less reliable are their judgements that are based on the signs of existence of a truth as defined by their axioms or conventions. Where the group may consist of only one individual (not really a group but for the sake of this argument I stick with that term) then I would consider, as a logical argument, that this judgement will be the least reliable of all even tho there is still the possibility that they may be correct or true.

    Not sure what you mean in the last two sentences, can you clarify?
    Regarding the 1st paragraph can a practitioner answer these questions reliably using only abductive reasoning, or doesn't he also require some some evidence from deductive and inductive reasoning to complete his decision making process?

    I agree that we all need to be able to introduce some abductive reasoning into our decision making processes. How ever we must also recognise when this leap of logic is a leap too far. How far are we prepared to go outside the accepted axioms and convention to implement our own intuitive system of belief and truths.
    Some go to far for the comfort of the 'keepers of the truth' and conflict arises, this is a good thing in my opinion.

    .

    And the above paragraph is the reason why we need imagination and knowledge.
    Knowledge will quell our imagination or intuition but intuition will allow us to make quantum leaps. The Keepers of the truth will prevent us all from leaping headlong into metaphysical fantasy. Not a bad system in all wouldn't you agree.

    Cheers Dave
     
  11. Frederick George

    Frederick George Active Member

    David

    As you used in your example, drug trials work for EBM because there is no "art" involved.

    Surgery and biomechanics can never be reduced to EBM because of the individualised art of practice.

    You've got to be kidding! Have you not heard of the Enlightenment a few hundred years ago?

    Each of us as doctors knows how to think. We use what we think will work. We keep it, change it, or drop it as we see fit.

    Sheep who simply follow what the "keepers of the truth" (who are they?) tell them to do are not doctors. They are technicians.

    Cheers
     
  12. I hereby nominate this as one of the candidates for "quote of the year".:good::drinks

    This is one of the reasons the arena works so well. Individually we are all flawed. We each have our biases, our gaps in knowledge and understanding and our inaccuracies in approach. However together, as a gestalt, we fine the wilder excesses curbed and the more rigid thought processes softened. Hopefully the truths are somewhere in the centre.


    I rather think there is a communication issue here. For eg, lets take a piece of inductive evidence, one of the studies which show little or no difference in outcome between pre fab neutral orthotics and a root neutral. Is this good evidence? For the most part yes. Does it contain "truth"? Probably. Knowing that, do I issue all pre fabs instead of neutral casts? Hell no.

    I think the truths Dave speaks of are the broad truths like physics, not protocols to be followed (as by a technician.)

    Kind regards
    Robert
     
  13. David Smith

    David Smith Well-Known Member

    Fredrick

    Do not your own words contradict the intention of your statement? I.E That we are free thinkers and do not need guidance from others.

    Enlightenment was supposed to be the freedom of everyone to loose the shackles of Dogma and use reason to think and speak freely for themselves without worry of persecution from the hierarchy. And yet your statement reinstates a new hierarchy as the only free thinkers ie the Doctors.

    You clearly say that technicians are merely sheep who only follow doctorine and protocol and by inference are not free to speak of things of which they know nothing and yet they can only be judged as knowing nothing by some preset standard of knowledge that are referenced to axioms that belong to the doctors.)

    Thereby lies the trick of enlightenment, it was only an illusion, just a change of knowledge values and hierarchy. As a doctor did you not first have to study and pass exams laid down by some superior. Were you allowed to make up your own theories about human physiology and be passed by the board because they only judged you on your ability to reason freely and not by how your knowledge compared to standard works. I think not! You have been educated using standard conventions and axioms of your time and your peers and superiors will expect you to reason in such a way as to adhere to the rules of their conventions. You may be allowed some elasticity in your thinking but to venture too far from the 'truth' will not be allowed without severe criticism or eventually, expulsion from those circles.

    I would say that it would be unusual or even impossible for some person to have experienced all that his knowledge allows him to reason. In other words you rely on the fact that others have communicated their experience to you and proven sufficiently that their experience was truthful. Can you now use this knowledge to reason freely. No you cannot be this free, you will always be tied to some system of convention or be considered outrageous or mad by your peers.

    Only God has the ability to think freely, we as humans, since we cannot experience everything, must conform to some preconceived point of reference, set of rules, convention and Axiom. The 'keepers of the truth, are are own collective conciousness within the group of a certain discipline. We may appoint elected guardians to oversee the day to day implementations of these conventions but if we as a group change our ideas then the elected guardians cannot hold onto the old conventions and maintain office and so they must change with our collective conciousness.

    All the best Dave
     
  14. David Smith

    David Smith Well-Known Member

    So

    to get back to the OP

    DrSha wrote
    As an overall opinion I would agree with this statement. There is not the time or the money to validate every technique with the evidence of inductive reasoning by experience.

    This where we require a different type of reasoning and that can be Deductive. The conclusions drawn from that deductive reasoning must use signs of truth drawn from pre existing conventions, such as physics and physiology. This is a safe and defendable position for the clinician to take.

    If this is not so and the reasoning is abductive then the clinician must be extremely confident of his appraisal of the evidence drawn from his own experiences and the conclusions drawn from them. Should such conclusions turn out to be a logical fallacy I.E. The conclusion, whilst having the appearance of being supported by the evidence or experienced events, is not valid and therefore the conclusion is fallacious. I would say that this can be a professionally and legally hazardous position for the clinician to take and should be approached with caution. On the other hand this intuitive reasoning will sometimes pay dividends in terms of elevating the knowledge base. It seems that these times are few and far between and more often enthusiasm for the concept outweighs logical reason in the mind of the proposer.

    I would suggest that even though some treatment modalities appear to be pure art they do have foundations in science or at least popular convention and are not true free thinking post hoc/cum hoc ergo propter hoc conclusions.

    Hear hear! But lets not get lost in the artists abstract fantasy either.

    The art may be in knowing how far not to go.

    Cheers Dave
     
  15. If finding the best treatment was the true motive for the action of all clinicians, with the primary driving motive not being monetary gain or self-glorification, then we would not need to worry so much about the actions of many clinicians and whether their treatments were the best available or not for the patient. However, I know, for a fact, that many clinicians choose treatments for their patients that will make them the most money, with little regard for the financial impact on the patient or whether or not this treatment is effective or harmful or not. It is because of these types of individuals, which are present in every healthcare discipline, that evidence-based medicine is essential to preventing these wrongly-motivated individuals from doing "what they think is best for their patients".
     
  16. Frederick George

    Frederick George Active Member

    This is becoming quite interesting and mulitfaceted.

    We have the windy philosophic point of view:

    Not at all. My intentionis that as doctors we have the ability to learn and THINK, and make our own determinations. We decide what works best for us, in our hands, and have the responsiblity and power to act on it. Certainly we are educated (please don't say trained, you train a dog), and continue to learn. But we decide what makes sense to us. We are surgeons, a combination of scientist and artist. I would hope that most don't just follow some authority figure.

    This is a very pragmatic view point. Technicians are limited in their knowledge and decision making capabilities. Simply put, they follow orders.

    It's true that some podiatrists follow orders, working as a poodle for orthopedists for example.

    Then there is the nazi point of view:

    [/QUOTE]

    What a sad commentary. To ascribe immoral motives to many other doctors' treatment plans because they disagree with one's personal opinion.

    Is this a case of projection?

    Exactly!! This is what we are supposed to do. But although you could say it's a form of EBM it's not what is meant by the term. It can't be reduced into statistics. It is disparagingly referred to as anecdotal.

    So, as with all things that are stupid, EBM as mantra of all medicine will pass.

    Cheers
     
  17. drsha

    drsha Banned

    Kevin Stated:
    "If finding the best treatment was the true motive for the action of all clinicians, with the primary driving motive not being monetary gain or self-glorification, then we would not need to worry so much about the actions of many clinicians and whether their treatments were the best available or not for the patient. However, I know, for a fact, that many clinicians choose treatments for their patients that will make them the most money, with little regard for the financial impact on the patient or whether or not this treatment is effective or harmful or not. It is because of these types of individuals, which are present in every healthcare discipline, that evidence-based medicine is essential to preventing these wrongly-motivated individuals from doing "what they think is best for their patients".
    Dennis Replies:
    EBM can become a lynchmob tool in the hands of the wrong people when used in the manner that Dr. Kirby aspires it to.
    I vascillate from placing Kevin as one of the most brilliant and dedicated educators and scientific thinkers in the biomechanics world to him being a most dangerous entity to validate in front of students and practitioners alike because of posts like this.
    He intertwines his personal, self prophetic agenda to divert debate with free thinkers away from the debate usinf an EBM defense.
    "I know, FOR A FACT, that many clinicians choose treatments for their patients that will make them the most money, with little regard for the financial impact on the patient or whether or not this treatment is effective or harmful or not", a Rothbart type amazingly personal and unproven statement that some might confuse with one of Kevins EBM statements.
    FOR A FACT my A_ _!!
    My Rothbart reply is “I know FOR A FACT that every practitioner who is free thinking and caring for the foot suffering public investigates all streams of new ideas and concepts, whether expensive or not, in order to develop an armarmentarium of care that is the best that can be offered”.
    I am currently investigating MediHoney ($30), ENFD Testing (a $110 test) and Platelet Rich Plasma Therapy (a $2000 treatment) and I am always looking for biomechanical improvements to my treatment paradigm without a profit motive.
    Does Kevin eliminate expensive gene therapy, stem cell research and all biomedical visionaries as “wrongly motivated”? If he does, he will find himself practicing a primitive form of Podiatry in a short time.
    My reposting the EBM Terrorism posting of Dr. Jacobs from Barry Blocks site was to alert those necessary EBM fellows who act as watchdogs for medicine to eliminate Charlatans and poorly conceived and unproven diagnostic and treatment modalities from surfacing as mainstream (remember the Washington Monument Incision?) that they are now unknowingly allowing insurance companies to defer reimbursment of new and exciting modalities that are upgrades and advances by using EBM Terror (not proven, not well researched, self funded studies, no longitudinal studies)/ They are turning the medical professions into cost effective technicians that allow Insurance Company CEO’s to ride in helicopters!! With good intention, you are becoming the unknowing slavedrivers for the masters of medicine.
    In summary, if Kevin succeeds in converting us into EBM, medial skiving, STJ Axis measuring, scanning, STJ Neutral shell orthotic makers and he banishes, abuses and ridicules those who offer alternatives from The Arena, then eventually, he will be the leader, judge and jury controlling the flow of an EBM based, stagnated, biomechanical mindset. He will be leading his followers into the dark side.
    “Where’s that picture of Darth Kirby when we need it?”
    :sinking:
    Dennis
     
  18. Dennis:

    Are you off of your medicine again??:rolleyes:
     
  19. David Smith

    David Smith Well-Known Member

    Fredrick

    You wrote
    Yes I know you just said that! but anyway, Do you propose that you have complete autonomy and self determination with your chosen discipline.?

    Are you saying this self determination is a result of your education?


    How do you make those decisions without deductive and inductive reasoning or scientific method?

    Also you wrote
    This is a very elitist point of view in my opinion. You elevate yourself to the position of free thinker and relegate all others to an subordinate position with the assumption that they are without this capability. And yet you appear to align with and support the position of the Enlightenment movement. Aren't these mutually exclusive propositions?

    Your argument, infers that, since you are a free thinker and subordinates cannot be free thinker, by definition you can have no superiors. This in turn would imply that you need not and do not make any reference to any convention or axiom that would restrict your free thinking. Subordinates are not capable of constructing valid arguments and superiors cannot exist and therefore you draw your own conclusion based solely on your own experience.

    To make a valid inductive argument one must experience everything contained within that arguments propositions. Further, you cannot say that an inductive argument is true when used to support a conclusion not entailed within the experience. I.E. where you extrapolate one event singular experience to make a universal conclusion about all others, the best you can do is make a prediction about the probability, unless you have experienced every event past, present and future.

    If you insist by these terms that you are still a free thinker then this raises you to the level of Deity since only a god can assume all experience past, present and futur which is what you would require to make truthful predictions based solely on personal experience. This seems and unlikely state of affairs for two reasons
    1) I assume you are only human with human limitations. 2) There is only one God and I assume its not you.

    Quite.:eek:

    Viereinhalb Jahre (des Kampfes) gegen Lüge, Dummheit und Feigheit -
    Four and a Half Years (of Fighting) Against Lies, Stupidity and Cowardice.
    What Hitler would have called his book finally named Mein Kampf.


    Guden taag

    Dave
     
  20. drsha

    drsha Banned

    Kevin.

    Yes, I'm off my medicine, my parents are siblings, I am demanding a refund from NYCPM for my cum laude, valedictorian degree and how futile and immature your response is.
    Dennis
     
  21. Sammo

    Sammo Active Member

    Dr Sha and Mr Hyde... which one will post next...???

    Who knows... :confused:
     
  22. drsha

    drsha Banned

    Sam Stated:
    Dr Sha and Mr Hyde... which one will post next...???
    Who knows...

    Dennis Replies:
    Professor Kevin Kirby and Darth Kirby... which one will post next...?
    Who knows...

    Why is one a sinner and one a saint and
    who is GOD?
    Dennis
     
  23. Gosh! How exciting! Seconds away round 3 ding ding etc.

    If we're choosing characters i'd like to be mace windu please.

    Well, looked at logically this is an inclusive statement. I don't know how many "many" is in this context but lets say any. I can certainly think of at least one clinic wherein patients have been charged grossly over the odds for devices when far simpler cheaper solutions were available.

    This, however,

    This, however, is an exclusive statement. To make a statement on EVERY practitioner one would need to KNOW EVERY practioner. Unless you argue that to investigate all streams of new ideas is what DEFINES a free thinking practitioner. In which case have you investigated thought field therapy?

    Its the difference between saying "I've a green mouse" (provable) and "ALL mice are brown" (provable only if one can invstigate all the mice in the world.

    EBM is a powerful tool indeed! But it is a tool available to all. The only people who need fear it are those who cannot use it!

    And lets face it, without Evidence based medicine what does that leave? Opinion based medicine? Hearsay based medicine? What, if not evidence, should be the basis for medicine?

    Regards
    Mace
     
  24. blinda

    blinda MVP

    The Generator Of Diversity
     
  25. Sammo

    Sammo Active Member

  26. Frederick George

    Frederick George Active Member

    It seems that my last post didn't make it in. Hmmmm

    Medicine as with science has been evidence based for what, at least 100 years?

    Is this rigid doctrine of EBM/RCT just a power play by the "keepers of the truth?"

    And who are they? What is the medication they're on?

    Power?

    Cheers

    Frederick
     
  27. Strong words indeed! I don't really see EBM as a rigid docterine so much as something to strive toward.

    If we could carry out a quality RCT of every intervention we do it would be a very fine thing. Unfortunatly, due to the N=1 nature of the human condition this is blatantly implausible. However that is not to say the idea of EBM and RCTs has no merit.

    Here is a question. The "lynchmob / powerplay" element of EBM, on this forum at least, is often leveled because a new idea / concept has been introduced and not embraced. By inference it is often suggested that people hide their closed minded prejudice / investment in the system behind the sheeps clothing of EBM.

    There is no doubt that we are ALL bias to our A priori assumptions. Both the "keepers of truth" AND those with new ideas.

    More than once it has been suggested to me that if i want some proof of the efficacy of something I should "just try it" and see for myself.

    But here is the thing. We are all vulnerable to suggestion and persuasion, particularly by skilled salespersons who abound in all walks of life. I suggest that individual experiance on the basis of "trying something" or "seeing it done" or even "having it explained" is a poor way to judge an innovation.

    Hypnosis / suggestion is great fun like this. You can have somebody act in an irrational way and then watch people twist logic until it screams to explain why they did what they did! And they honestly beleive what they are trying to explain!

    Wittness Mr Catto's demonstration of how a proprioceptive device improved somebodies stability in static WB after doing ten squats on it. Podiatrists, intelligent degree trained podiatrists, were convinced by this (and not just a few)! After Mr Glasers presentation at the osteotec conference I had a Podiatric surgeon suggesting, in all seriousness, that I should desist from using any form of wedge, post or skive and rely on the MASS position instead "because it made sense and he is getting really good results". Consider the Dentron Biogun.... death rays for verrucae! How many degree or docterate trained people prescribe 40c homeopathic solutions (or "water" as its otherwise known) in the honest belief that it has a theraputic effect beyond the placebo?

    Of course we all tend to think that the truths WE accept are real and only other people have been duped. This is so obviously fallacious. I dare say we all hold some views which are wrong and worse that we convince others of them! THAT is why I think we must be so careful about what we say. There is a world of difference between "this is what I think to be true" and "I think this BECAUSE it it true".

    Most of the "dominant" models are based, loosely, on premises we KNOW to be sound. Like Physics. However they offer no absolute protocols. Most of the ideas which have been flamed are very specific protocols.

    So how then should we judge a "new idea"? The scientific method, at its best, has developed precisely with the intent of removing these gross sources of error inherent in the human condition. To deny EBM is the cerebral equivilent of the MASS docterine. It takes a useful development OUT of the equation and returns to what we had before, repackaged in shiny new clothes.

    Regards
    Robert
    Power mad EBM junkie.
     
    Last edited: Apr 23, 2009
  28. drsha

    drsha Banned

    Robert Stated:
    My Rothbart reply is “I know FOR A FACT that EVERY practitioner who is free thinking and caring for the foot suffering public investigates all streams of new ideas and concepts, whether expensive or not, in order to develop an armarmentarium of care that is the best that can be offered”.
    This, however, is an exclusive statement. To make a statement on EVERY practitioner one would need to KNOW EVERY practioner. Unless you argue that to investigate all streams of new ideas is what DEFINES a free thinking practitioner. In which case have you investigated thought field therapy?
    Dennis Replies:
    Once again, I learn from The Arena and will reduce my use of nevers, always and everies when making points. Thank you Mace.

    Robert Stated:
    EBM is a powerful tool indeed! But it is a tool available to all. The only people who need fear it are those who cannot use it!
    You are so right but The Arena mistake is that as researchers, they skew the research with their bias.
    I do not fear research or EBM. I DO NOT PERSONALLY DO RESEARCH.

    The sad truth which may or may not come to light here (and which has been abused every time I state it) is that while your great minds are focused on protecting patients (I assume) from Charlatans and money hungry people, you haven't used that time to examine new paradigms of care developed by those of us who have dedicated our time to do so.
    You just bury us (and I say that for the past as well i.e. is Root dead?)

    Personally, I could make a great living selling paint! The fact that I have chosen to sacrifice loved ones, friends and my personal energy for 40 years to devote to helping the foot suffering public as my primary motive does not deserve to be obscured into Neurotic Biomechanics an patenting.

    Dennis
     
  29. David Smith

    David Smith Well-Known Member

    Robert

    Obviously you and I are on the same wave length, which is cool :cool:

    There appear to be two camps in this discussion

    1) Those that extol the logical exoteric argument I.E. formal logical progression of an argument that entails well known or universally accepted truths

    2) Those that favour the emotional esoteric argument I.E. Argument that entails how they feel about a subject or theory and the individual knowledge or experience held only by those persons, which they interpret as truth.

    Now Robert, perhaps you might be able to answer, which of these two methods is more Heuristic in nature, if we consider that Heuristic reasoning is a 'common sense rule (or set of rules) intended to increase the probability of solving some problem, suggesting that trial and error experimentation within one's own experience will achieve reasonable conclusions most of the time.

    Is it more common sense to use 1) a priori knowledge and universal concepts or 2) post hoc evaluation of one's own experience to come to a conclusion about a certain event.

    If 2)is more correct, can we think freely enough to disregard a priori knowledge and concepts and only base conclusions on experience of the event of interest?

    From what I understand, heuristic problem solving is more reliable when scores from groups are aggregated to get mean 'guess' which will represent the most reliable solution to a problem. The more variables within a certain problem the less likely it is that a single person will give a reliable solution.

    Therefore this method of solution finding is really a kind of inductive reasoning based on intuitive and retrospective experience of groups. Unlike abductive intuitive reasoning of a single person where the conclusion is highly unreliable in that it may be spot on or wildly inaccurate.

    What are your thoughts?

    Cheers Dave
     
  30. drsha

    drsha Banned

    Dave:
    Your thought is so very black and white that it makes me gray to read them.

    You get offended when I point out that I am not so dogmatically rigid on the subject of logical exoteric debating

    and then have no qualms about verifying the value of a foam box, internet generated foot insert as valuable because you are dispensing it when we all know that logically and exoterically it is a piece of crap that should not be mistakenly considered as gold standard or valuable by the foot suffering public because of professional endorsement.
    I guess your orthotic for poor people rational is exoteric?????
    Please apply your debating skills to you own way of working in addition to mine and I will have more respect.
    Dennis
     
  31. Ian Linane

    Ian Linane Well-Known Member

    Being of a somewhat simple mind I wonder if, within musculoskeltal / biomechanical realms of pt care, we can ever say we practice Evidence Based Medicine. With so many variables that impact upon a diagnosis and then treament plan and then find such plan to have to be altered after the first hurdle perhaps we need to alter the definition as it applies to us. So we could argue (semantics I know) that we operate on a basis of Evidence Based Care. So we might in that context consider the researched data and protocols and value them but equaly value and consider more anecdotal aspects that we have found successful. This latter perhaps having it home in the moments after collapse at the first hurdle!

    Cheers
    Ian
     
  32. Nor do I. But I do respect it when others do it. Unless its poo of course.


    Hmmm. I take your point here actually. There is always a risk that one gets too attatched to looking for bad developments and becomes jaded. I would like to think, however, that we are not universally like this. I can think of many ideas to appear on the arena which have been examined and applauded, and not just those offered by the elite!

    :eek:

    [​IMG]

    ;) Kidding. Pax.

    R
     
  33. David Smith

    David Smith Well-Known Member


    Why, man, he doth bestride the narrow world
    Like a Colossus, and we petty men
    Walk under his huge legs and peep about
    To find ourselves dishonourable graves.

    Ah DrSha, That you do love me, I am nothing jealous;
    What you would work me to, I have some aim:
    How I have thought of this and of these times,
    I shall recount hereafter; for this present,
    I would not, so with love I might entreat you,
    Be any further moved. What you have said
    I will consider; what you have to say
    I will with patience hear, and find a time
    Both meet to hear and answer such high things.
    Till then, my noble friend, chew upon this:
    Brutus had rather be a villager
    Than to repute himself a son of Rome
    Under these hard conditions as this time
    Is like to lay upon us


    Yet if my name were liable to fear,
    I do not know the man I should avoid
    He reads much;
    He is a great observer and he looks
    Quite through the deeds of men:
    he loves no plays,
    As thou dost, Antony;
    he hears no music;
    Seldom he smiles, and smiles in such a sort
    As if he mock'd himself and scorn'd his spirit
    That could be moved to smile at any thing.
    Such men as he be never at heart's ease
    Whiles they behold a greater than themselves,
    And therefore are they very dangerous.

    Come on my right hand, for this ear is deaf,
    And tell me truly what thou think'st of him.



    Shakespeare - Julius Caesar Act 1 scene 2 - misrepresented.

    Now you've got the anger out of your system, have you got anything relevant or interesting to add to this discussion or do you just want to rake over old ground that really only adds to your chagrin.

    Regards Dave
     
  34. David Smith

    David Smith Well-Known Member

    Ian

    Eh?

    LoL Dave
     
  35. :drinks Good init!


    I like the esoteric / exoteric idea. There is, however, a problem here.

    The vast majority of people will opine that they hold their view because of logical progression of thought, ie argument -> conclusion. Its a brave and remarkable self aware person who thinks otherwise (we both know a few)! Its easy to see IN OTHERS when someone has done it the other way around and sought to find a logical argument to support the opinion they developed via esoteric / heuristic reasoning. Its very hard to see in oneself.



    Thats a tricky one! I'd say that heuristic reasoning is rife in both! In the second, if one is honest and self aware, it is easy to see. Take, as an example, selection bias. How much more do we "weight" the success of a distressed and suffering patient against the failiure of a stoic one? If working from an empirical view this is easy to detect.

    HOWEVER

    Heuristics can be as rife in the more "logical" approach. Often when dealing with research it is easy to think that heuristics are not being used. They are! Not only are we reliant on the reasoning of the person who design and wrote the research, we also use heuristics in interpretation thereof. These are more subtle and can be harder to spot without training, but they are none the less present!

    Its hard to say in general terms.

    Here I would disagree. Error, certainly, gets ironed out across numbers. Heuristics , however, can be fairly repeatable and even large groups can get it dead wrong! Remember the examples in the talk I gave? Pretty reliable to decieve even in a group of trained people!

    Kind regards
    Robert
     
  36. For the benefit of those who wonder what the hell Dave and I are talking about, here are a few little tests on how our brains can trick us! These are part of a talk I give on heuristics. They've been on the arena before so if you remember the answers from last time, please don't spoil it for the rest. Please try them and WRITE YOUR ANSWER down before scrolling down to see what others write, and put what you came up with honestly (even if you get a different answer. Consider, if you will, that you are approaching these KNOWING they are logic puzzles. If you were were reading them in research of in the media you would answer quickly and with less thought.

    Please all have a go, it'll be an interesting experiment.

    Q1

    There is a horrible and fatal disease which affects 1 in 10,000 people. I have designed a test for this disease which is 99% accurate.

    I test you and you test positive.

    What is the probability you have the disease?

    Q2

    I have 4 cards. Each has a letter on one side and a number on the other. I lay them before you thus.

    A F 3 7


    The hypothesis is this. "If a card has an A on one side it has a 3 on the other". What is the smallest number of cards, and which is it / are they, needed to test the hypothesis?

    Have a go!

    Regards
    Robert
     
  37. David Smith

    David Smith Well-Known Member

    Robert

    Yes, I was forgetting this option.

    I had a vision in a dream about knowledge. That day I had been participating in the EBM debate and read Genisis (The scripture not the rock group)

    The tree of knowledge tall with smooth bark and bearing fruit. Three serpents of reason, deduction, induction and intuition, sit at its base and want to climb the tree and eat the fruit of knowledge. None however, can climb the tree by themselves due to the smooth shiny bark. They, together entwine the trunk and themselves and proceed to climb. Each one wants to reach the fruit first and fights the others. However as the coils of one squeeze the others it also squeezes itself, They know if one dies from the bite of another, two are unable to climb by themselves. One cannot advance by itself yet fights to hold the other two back, and so they persist, trying add infinitum to ascend but never really progressing.

    If they do reach the fruit what then? enlightenment? what is enlightenment? all the facts that ever where and ever will be laid at your feet.

    Some one famous said something like - 'all knowledge is just worthless facts, a phone book contains millions of facts and yet they are nothing more than dust in your ears'.

    Perhaps one day we could all brush the dust from our ears and listen to the true word of enlightenment. Aye and one day - :pigs::pigs:

    Just some esoteric rambling for you to ponder on :dizzy: Now where's my medicine!;)

    Sweet! Dave
     
  38. efuller

    efuller MVP

    Dennis, we have been examining your paradigm. I'm still waiting for you to explain a few things about it.

    How does the shape of the orthotic change for the different foot types?
    Do you find that you can see high arched individuals and low arched individuals within the same foot type? Do you give them the same orthotic?

    You have made many claims. I can understand not having the evidence for them yet, but I would at least like a rationale for why you would think that it would work. For example you talk about balancing the rearfoot to the 3 body planes. Could you explain how you know when a rearfoot is balanced relative to something.

    Dennis, could you not complain about how we won't examine your paradigm until you answer these questions. You can't expect me to try something if you can't explain what it is.

    Cheers,

    Eric Fuller
     
  39. And there lies the problem. Dennis CAN'T explain his model in terms we understand! As he keeps saying, he does not speak the same language or terminolgy as us!

    Perhaps the model would hold up to examination, perhaps it would not, but if he does not understand our questions, and we can't understand the answers, we cannot "examine" the model in any sense but the most superficial. Perhaps this is the root of all the frustration around these threads.

    He's talking 4 candles, we're hearing fork handles.

    And, btw, I'm personally hurt that nobody tried my questions! ;-)

    Regards
    Robert
     
  40. David Smith

    David Smith Well-Known Member

    Robert

    They were far too difficult for me and I've done them before, there are at least 6 answers to each question and I have no idea which is the right one. But most importantly I'm not going to be the Oliver Twist or Oedipus to your Sphinx in this scenario and get thrashed or eaten alive for dariong to speak up. You know me I'm a bit shy in these things.

    LoL Dave :)
     
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