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Rapid Responses: Rapid Responses published:
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Above all, Students need to learn Biophysical Semeiotics.
- Sergio Stagnaro (7 March 2003)
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Evidence-based medicine - the emperor's new clothes?
- Niall Boyce (7 March 2003)
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EBM and Common Sense(which is uncommon)
- John J. Plunkett (9 March 2003)
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How to Pass Finals. Rule No. 1 - Be Safe
- Oliver W Donaldson (18 March 2003)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseaes. Researcher in Biophysical Semeiotics Via Erasmo Piaggio 23/8 16037 riva Trigoso (Genoa) Italy.
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Sirs, All around the world, every general practitioner knows very well that, although evidence based medicine is increasingly emphasised and taught in medical schools, applying literature findings to “clinical” decisions on a “single” patient, in his (her) surgery, is a really different enterprise. In my mind, there is tool of paramount importance for physicians who are working at the bed-side, in day-to-day practice, in a world otherwise ruled by high technology. In fact, I think that there is something wrong at the base of Evidence Based Medicine argumentation, which, unfortunately in my mind, has become the rule of present “clinical” medicine. For instance, one can realize that there are patients with certain test results more likely to have the target disorder, and then test results distinguish patients with and without the target disorder among those in whom it is clinically sensible to suspect the disorder. The authors know, generally, only the old, traditonal, acadèmic physical semeiotics, but either ignore or overlook the developments, that have occurred in the past 50 years, in physical semeiotic field (1,2,3). In fact, nowadays, all diagnoses must be, and can, be first “clinical” and then corroborated by laboratory and/or image department (performed always in patients rationally selected), despite the statements of EBM. In addition, under such circumstances, if a test result is pathological, but clinical examination, i.e. the clinical result of biophysical semeiotics (See: HONCode site 233736, http://digilander.libero.it/semeioticabiofisica), is normal (I ask: “Why” an individual, evaluated at the bed-side in health condition, must undergo an instrumental or laboratory examination?) and this “patient” is working all day long and is able even to perform physical exercise, physician is allowed, under such (really numerous) conditions, to state that laboratory and image department are wrong, even performed according to EBM. Sergio Stagnaro MD., Active Member NYAS. 1) Stagnaro-Neri M., Stagnaro S., Deterministic Chaos, Preconditioning and Myocardial Oxygenation evaluated clinically with the aid of Biophysical Semeiotics in the Diagnosis of ischaemic Heart Disease even silent. Acta Med. Medit. 13, 109, 1997. 2) Stagnaro-Neri M, Stagnaro S., Valutazione clinica percusso-ascoltatoria del sistema nervoso vegetativo e del sistema renina-angiotensina, circolatorio e tessutale. Arch. Med. Int. XLIV, 3, 173-178,1992. (Infotrieve) 3) Stagnaro-Neri M, Stagnaro S., Valutazione clinica percusso-ascoltatoria del sistema nervoso vegetativo e del sistema renina-angiotensina, circolatorio e tessutale. Arch. Med. Int. XLIV, 3, 173-178. (Infotrieve) Competing interests: None declared |
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Niall Boyce, Medical Student Oxford University Medical School
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This paper has put the finger on a few of the aspects of the drive towards evidence-based medicine that I feel uncomfortable with. In short, whilst the shifting of medical practice to a firmer evidence base is desirable, I'm not sure whether it represents the leap forward that it's sold as. From what I can see, the "evidence-based medicine" bandwagon consists of simply applying new technologies, such as the advanced search techniques computers afford, to the long-established idea of actually basing treatment decisions on scientific evidence. Secondly, the emphasis of this technology and the condensation of medical evidence into a few lines of text represents a real risk of forming a dogma and not equipping new doctors to question it. During my evidence based medicine teaching sessions, I was told that all our essential reading need consist of as a hous officer was "reading the contents page of Evidence Based Medicine". Hardly encouraging critical thought! I don't think that medical students should be encouraged to just search the web, and leave the thinking to someone else. Competing interests: None declared |
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John J. Plunkett, Laboratory and Medical Education Director Regina Medical Center, 1175 Nininger Rd., Hastings MN 55033
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A reminder about using EBM: LOOK for evidence to support your opinion or treatment decision; IF there is evidence, critically evaluate it, and apply it IF it passes muster; IF there is not, ACKNOWLEDGE so, and go on to your next move, based on whatever criterion you choose. Competing interests: I frequently consultwith defense attorneys in cases of suspected child abuse. |
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Oliver W Donaldson, PRHO Paediatrics Southmead Hospital, Bristol, BS10 5NB
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Some of the conclusions this paper raised, I feel, were a little unfair. As a medial student, one of the first rules that you learn to pass finals is to be safe. If you manage to get through the final examinations without appearing to harm or endanger your patients’ health then you have virtually passed. This is something that seemed to be emphasised at an early stage, certainly at my medical school. The medical students within this study probably entered into their finals with this in mind. It is impossible to say how much experience each medical student had in managing patients with neck pain following trauma, but the likelihood is that it was limited. Therefore, they were being asked, in an examination setting, to manage a patient with a relatively unfamiliar condition. Surely in these circumstances a medical student is being safe by requesting an x-ray in order to rule out fractured cervical spine, bearing in mind they are in the USA where litigation is a common occurrence. The study also did not allow the students to re-examine the patient after they had read the evidence-based medicine. Only 11% of the medical students actually fulfilled the three manoeuvres that would enable them to make a fully informed decision as to whether an x-ray is needed for this patient. Therefore, regardless of the quality of evidence given, the majority are unable to make a decision of this magnitude anyway. Again, the likelihood is that most of the medical students will, in fact, be safe and request an x-ray. A medical student has a tricky time balancing evidence-based medicine with managing patients safely, but surely the emphasis should be on safety first. Competing interests: None declared |
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