Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Effervescence-based Medicine
- Frank O'Brien (17 December 1999)
-
Webidence-based Medicine
- Bruce Slater (17 December 1999)
-
Evidence based medicine rating scale
- Thomas P Bleck (18 December 1999)
-
e-literature
- Carl J Hauser (20 December 1999)
-
Evidence vs. Acumen
- Rod McClymont (20 December 1999)
-
Women and Medical Eminence
- Bebe Loff (20 December 1999)
-
Profit-Based Medicine (aka Opulence Based Medicine)
- Gunther Eysenbach (20 December 1999)
-
Rheumatism-based medicine
- Luiz Claudio da Silva (20 December 1999)
-
Annoyance based medicine
- Steven Ross (21 December 1999)
-
Unqualified Success and Unmitigated Failure--indices of NNT and NNH
- Gian Franco Gensini, Andrea A Conti (23 December 1999)
-
Propaganda based medicine
- Aldo Mariotto (27 December 1999)
-
Arrogance based medicine
- Arthur M Lam (17 January 2000)
-
Narrative based medicine
- Aldo Mariotto (8 February 2000)
|
|
|||
|
Frank O'Brien, Quality Improvement Officer Fremantle Hospital & Health Service
Send response to journal:
|
In an otherwise excellent review of the subject, the authors (surprisingly, in view of the season) omitted one important alternative, "Effervescence-based medicine". It is practised by physicians who have taken too much bubbly at the hospital Xmas party, and is marked by slurred speech and ataxia. Measurement by breathalyser will result in removal of the driving licence. |
|||
|
|
|||
|
Bruce Slater, Assistant Professor George Washington University, Wash, DC, USA
Send response to journal:
|
Sirs: Excellent review of alternative practice justification methods. May I suggest yet another method of persuation practiced by the medical digiterati. Webidence is scientific (type 1) and pseudo-scientific (type 2) medical advice and opinion posted on a web site (first defined here?). The marker for this is "sticky eyeballs", the measuring device is the web hit counter, and the unit is the unique hit and repeat visit count. Unfortunately no reputable authority exists for separating type 1 and 2. Perhaps a market niche? I have no competing interests other than a desire for clinically relevant patient focused advice at the point of care. |
|||
|
|
|||
|
Thomas P Bleck, Professor of Neurology, Neurological Surgery, and Internal Medicine University of Virginia, USA
Send response to journal:
|
I read the paper of Isaacs and Fitzgerald with great interest and amusement. I am a skeptical proponent of evidence-based medicine, but would add the definition that it is a system of belief that requires prospectively collected objective evidence of everything except its own utility. In the same vein as Issacs and Fitzgerald, I suggest the adoption of the following as a realistic evidence-based rating scale: Class 0: things I believe Class 0a: things I believe despite the available data Class 1: randomized, controlled clinical trials (RCCTs) that agree with what I believe Class 2: other prospectively collected data Class 3: expert opinion Class 4: RCCTs that don't agree with what I believe Class 5: what you believe that I don't |
|||
|
|
|||
|
Carl J Hauser, Associate Professor of Surgery UMDNJ / New Jersey Medical School
Send response to journal:
|
Those active in internet discussion groups will recognize the evolution of a new form of scholarly writing, which I propose should be called the "Case report and review of the e-mail". These are presently neither recognized by the Science Citation Index, nor listed by Medlines or the like. Nonetheless, they can be of value, and certainly can be more worthy of quotation than say, "how I do it" articles, invited reviews, published symposia, or even occasionally front page page articles in the NEJM which were supported by large grants from drug companies and which have predictable conclusions. I have actually seen one physician try to cite comments originally posted on a proprietary web site in a journal submission, but that was an Emergengy Medicine physician, so I'm not sure what it meant. In any case, we should be aware that as we enter the information age, many worthy sholarly efforts will continue to go unrecognized while others will continue not to worth the paper they're written on. | |||
|
|
|||
|
Rod McClymont, Locum Consultant Paediatrician and Adolescent Physician North West Regional Hospital, Burnie, Tasmania
Send response to journal:
|
I must congratulate Issacs and Fitzgerald for their contibution to this vital aspect of medical practice theory. Hopefully their paper will stimulate further thought and discussion on why we REALLY do what we do. Issacs has published previously on the subject of clinical acumen (1). Evidence-Based clinical practice is all very well in principle but when applied without acumen, frequently becomes just more Vehemence-based or even (with apologies to Prof. @#$%#)Eminence-based medicine. My local area is currently experiencing a minor epidemic of Webidence(2)-based, multilevel marketing company propaganda extolling the virtues of a patented nutritional supplement that is said to cure most ills. In some cases, a clinical acumen deficiency has played a significant role. 1.Isaacs D. Occult bacteremia or occult clinical acumen? Curr Opin Pediatr. 1996 Feb;8(1):1-2 2. Slater B. "Webidence-based Medicine", eBMJ December 17, 1999 |
|||
|
|
|||
|
Bebe Loff, NH&MRC Scholar Department of Epidemiology and Preventive Medicine, Monash University
Send response to journal:
|
Having some doubts about the religous zeal surrounding EBM, I greatly enjoyed "Seven alternatives to evidence based medicine". However, I was dismayed to see that until women begin to suffer from balding we cannot achieve the "halo" effect, presumably reserved for those most eminent. The piece is well placed in an edition of the Journal that also contains "Babes and boobs". No competing interests other than female status. |
|||
|
|
|||
|
Gunther Eysenbach, Researcher Unit for Cybermedicine, Dept. of Clinical Social Medicine, University of Heidelberg
Send response to journal:
|
One alternative - which may be especially prevalent in private practice and fee-for-service based remuneration systems - is definitively profit-based medicine (also known as opulence based medicine): The conscientious, explicit and judicious use of the most profitable and lucrative interventions when making decisions about the care of individual patients. |
|||
|
|
|||
|
Luiz Claudio da Silva, rheumatologist Universidade Federal de Mato Grosso do Sul - Campo Grande - BRAZIL
Send response to journal:
|
In Brazil, many physicians found out a specially safe way to practice medicine that we can define as "Rheumatism-based medicine". In that practice the diagnosis is very simple. A patient with articular pain always has rheumatism. There's no way to make mistake. In rheumatism-based medicine a patient with articular pain always has and always will have rheumatism. If making diagnosis is that simple, so is next work. Requesting the following tests: blood cell count, erythrocyte sedimentation rate, antinuclear antibodies, rheumatoid factor, LE cell test, antistreptolysin O titers (ASO), serum urate, protein electrophoresis, mucoprotein,and C- reactive protein. The objective is to know what is the rheumatism type, and to do that, there is no need of thinking. If diagnosis is always rheumatism the tests are always the same. It's very simple. If any of the tests shows abnormality the rheumatism type is blood rheumatism. If antinuclear antibodies are positive, the blood rheumatism is named lupus and if the rheumatoid factor is positive, it't named rheumatoid arthritis. If ASO is high they call it rheumatic fever. If tests are normal so the type isn't blood rheumatism. Maybe it's nervous rheumatism, bone rheumatism or any other like those, but they are very rare types and then new tests will be necessary. As soon as the work to identify the rheumatism type is finished, next step is the treatment. The most frequent rheumatism type is blood rheumatism and in this case benzathine penicillin is always used monthly, weekly or daily, with or without corticosteroids and nonsteroidal anti- inflamatory drugs. If the serum urate is high, then allopurinol is added. The prognosis is very bad because there's no cure for rheumatism, and the patient has to take medicine forever, and has to come back to the physician office to repeat the blood tests monthly. The objective is to normalize the test results, and the doctor, that never is guilty because of the faults that are consequence of the bad rheumatism, always has the glory for eventual successes that seem to be result of placebo effect. Brazilian peopel believe in that practice and while a few rheumatologists fight lonely against that quackery, many united "rheumatismologists" take advantages of this mine of gold, exploring the ignorance of the society. |
|||
|
|
|||
|
Steven Ross, Professor of Surgery Cooper Health System
Send response to journal:
|
An additional class might be titled 'Annoyance based medicine' or 'Avoidance based medicine'. This occurs when a patient, family, or other practitioners become so annoying in their demands for a specific course of care, that the physician gives in. e.g.: The mother who demands antibiotics for her childs colds; The patient who demands unnecessary diagnostic tests incessantly, until through nagging, the physician orders them; THe Internist who is convinced that his patients problem is due to his gallbladder, who refers to a surgeon repeatedly until he/she gives in and does a cholecystectomy (usually not relieving the patients symtoms) |
|||
|
|
|||
|
Gian Franco Gensini Department of Internal Medicine and Cardiology, Florence Medical School, Andrea A Conti
Send response to journal:
|
An interesting paper by GBJ Mancini and M Schulzer (1) has appeared in Circulation in 1999. In it the authors, recalling their previous proposal (2) of adding, to the consolidated NNT (Number Needed to Treat), the index us = "unqualified success", and to the NNH (Number Needed to Harm), the index uf = "unmitigated failure", have proceeded to calculate the clinical impact of these two indices by analysing 11 clinical trials from cardiovascular literature. The authors define NNTus as a measure of the degree of therapeutic effort necessary to prevent death in the patient without incurring in any serious, treatment-induced side effects, in other words, the ideal success all clinicians aspire to, and NNHuf as an estimation of the level of therapeutic effort expended before the patient experiences both treatment- induced side effects and death, or, in other words, the dismal situation all clinicians hope to avoid. It is our belief that a retrospective, methodologically controlled and not randomly assigned comment on the potential clinical applications of the above parameters may be useful in underlying potentialities and limits of an EBM quantitative approach. NNT and NNH (3,4) are well-known parameters that provide quantitative information based on the type of intervention, its duration and the adverse outcome that the intervention itself attempts to prevent. NNT is calculated as the reciprocal of absolute risk reduction, NNH as that of absolute risk increase, and both must be accompanied by a 95% confidence interval, i.e. the range of values, computed on the basis of sample data, that includes the real value of the studied parameter in 95 out of 100 cases (5). NNTus and NNHuf can be considered as statistic - and, that is even more important, linguistic - refinements of the NNT and NNH concepts, since, with their "evident" expressions of lexical absoluteness, they appear to aim at representing a more exact way of indicating the quantitative benefit and quantitative harm parameters of the therapeutic approach under consideration. In fact, these treatment-specific indices emerge from the comparison arms of trials, the therapeutic outcome under study, the length of treatment necessary to reach the studied outcome, and the treatment-related adverse effects. They also furnish really relevant quantitative indications to allow the making of decisions in the allocation of medical services and economic resources. Some limits in the adoption and the use of these parameters must nonetheless be signalled, despite their eminence and effervescence (6,7), such as the restriction of their usefulness in the comparison of different diseases only to those cases in which the length of therapy and the outcomes are similar, their being punctual, rather than dynamic, estimations, always requiring a 95% CIs indication in order to furnish relevant clinical information, and the need for further methodological research on the application and validation of NNTus and NNHuf in clinical settings other than the cardiovascular one, as well as in sets of trials with different methodological designs and in a higher number of patients. In the light of a broad Evidence-Based, and not only NNT-based approach, and in spite of their evident limitations, NNTus and NNHuf emerge as interesting in their potential relevance, and are proposed to provide a reliable colour picture of the enormous clinical effort necessary to achieve an objective balance of benefits and harms, a balance that clinical practice daily tries to pursue with the great aid of Evidence-Based Medicine and associates (7). Gian Franco Gensini Andrea A. Conti Department of Internal Medicine and Cardiology, Florence Medical School, Viale Morgagni 85, I-50134, Florence, Italy. Italian Centre for Evidence Based Medicine Acknowledgments: GFG and AAC each contributed half the comments and will
both act as guarantors.
REFERENCES 1) Mancini GBJ, Schulzer M. Reporting risks and benefits of therapy by use of the concepts of unqualified success and unmitigated failure. Applications to highly cited trials in cardiovascular medicine. Circulation 1999; 99: 377-83. 2) Schulzer M, Mancini GBJ. "Unqualified success" and "unmitigated failure": number-needed-to-treat-related concepts for assessing treatment efficacy in the presence of treatment-induced adverse events. Int J Epidemiol 1996; 25: 704-12. 3) Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine. How to practice and teach EBM. Churchill Livingstone, New York Edinburgh London, 1997. 4) Greenhalgh T. How to read a paper. The basics of evidence based medicine. BMJ Publishing Group, London, 1997. 5) Everitt BS. The Cambridge Dictionary of Statistics in the Medical Sciences. Cambridge University Press, London, 1995. 6) Isaacs D, Fitzgerald D. Seven alternatives to evidence based medicine. BMJ 1999; 319: 1618. 7) O'Brien F. "Effervescence-based Medicine", eBMJ December 17, 1999. |
|||
|
|
|||
|
Aldo Mariotto, Head Unit for Technology Assessment and Quality Assurance, Local Health Unit n. 16, Padova, Italy
Send response to journal:
|
The short report "Seven alternatives to evidence based medicine" (1) skilfully depicts the consensus and decision-making processes which are adopted in actual practice. I do, however, believe that a commonly used eighth alternative has been neglected, namely propaganda-based medicine. If a physician only has a limited amount of time for scientific training, if he swallows anything he is told, or if he finds himself in any other unmentionable circumstance (2), he may fall prey to the interested pharmaceutical representatives who possess the best strategies for physician-changing behaviour. As the basis for clinical practice, there are two types of propaganda -based medicine: A and B. The markers are: type A) Gullibility level; type B) Unexplainable variation in consumption of drugs and reactives. The measuring devices are: type A) Reactions to a test such as the following: you have a forty-thousand-legged spider on your back, how do you react? Type B) A piggy bank. The units of measurement are: type A) Rate of frightened responses to the spider test; type B) $. I fear that the only real reason for non inclusion of propaganda- based medicine, at least in the type A format, is that the term does not rhyme with "ence". References 1. Isaacs D., Fitzgerald D. Seven alternatives to evidence based medicine. BMJ 1999; 319: 1618. 2. Folk rumours. |
|||
|
|
|||
|
Arthur M Lam, Professor of Anesthesiology University of Washington, Harborview Medical Center
Send response to journal:
|
I enjoyed reading the alternatives to evidence based medicine and the various responses from other readers. I wish to add "arrogance based medicine" to the list. This is particularly relevent in teaching hospitals where opinions are given out as fact, and no explanations are needed. The measuring device is phrase count. The unit of measurement is the phrase "because I said so." Admittedly this overaps with eminence based medicine and eloquence based medicine. |
|||
|
|
|||
|
Aldo Mariotto, Head Unit for Technology Assessment and Quality Assurance,ULLS 16, Via Delle Palme 15,35100 Padua,Italy
Send response to journal:
|
The article "Seven alternatives to evidence based medicine" (1), which is very close to reality, seems to establish a new classification in the Art of Medicine. Considering the potential enrichment and differentiation which the subject is achieving, I would like to propose a small but practical nosological contribution. Eminence-, eloquence-, and confidence-based medicine could be grouped into the single specialist branch of 'narrative-based medicine' (a term borrowed from the qualitological vocabulary of Carlo Favaretti, MD). Notwithstanding the individual disciplines, each of which may boast a longstanding tradition, even at University, their strong chit-chat- rather than fact-based component makes them so similar to justify the suggested aggregation. References 1. Isaacs D., Fitzgerald D. Seven alternatives to evidence based medicine. BMJ 1999; 319: 1618. |
|||