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EDITORIALS: Sharon E Straus and Giselle Jones What has evidence based medicine done for us? BMJ 2004; 329: 987-988 [Full text]

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Can evidence overcome training?

Harold A. Maio   (2 November 2004)

EBM

Edward Stone   (9 November 2004)

Evidence based medicine in favor of biomedicine and it seems that holistic medicine has been forgotten?

Søren Ventegodt, Trine Flensborg-Madsen and Joav Merrick   (11 November 2004)

Can evidence overcome training? 2 November 2004
Harold A. Maio, consulting editor home, Ft Myers FL 33907 Send response to journal: Re: Can evidence overcome training?	Another barrier is that providing evidence from clinical research is a necessary but not sufficient prerequisite to change behaviour and improve patient care. Giselle: I believe there is an answer to the above: Overcoming a trained behavior is far more difficult than simply providing evidence. As the consulting editor of a mental health journal, I regularly work with authors who know that language has changed, humanized, and that evidence supports the changes, but for whom particular words are so deeply ingrained they actually do not "see" the language they employ in clinical research. In repeating, often redundantly, metaphors whose time has passed, they impose trained behaviors, displacing evidence: Word is Deed: Wittgenstein My response to one was, " I heard everything you wanted to say, but your words contradicted your message." He hired me to edit. For him it remains a struggle, for others a practical impossibility. Harold A. Maio Consulting Editor Psychiatric Rehabilitation Journal Boston University Competing interests: None declared
EBM 9 November 2004
Edward Stone, GP BL9 5JN Send response to journal: Re: EBM	Editor-having read most of the recent BMJ edition devoted to EBM- 30/10/04, No. 7473-I confess to being little the wiser. I cannot remember when it became fashionable to use the term EBM though have found it largely irrelevant to my work as a GP. I glance occasionally at the BMA's Clinical Evidence though afterwards wonder if it is worthwhile doing anything for anyone! EBM seems all about clinical trials and, for most of the problems I face, such trials have either not been done or , if they have, I have neither the time or the expertise to evaluate the results.Of much more value is empirical observation along with prior knowlege and information gained from book, journals,hospital letters and consultation with GP and specialist colleagues.The crucial question is Does it work for my patients? and clearly I am now in a better position to answer it now than I was 25 years ago when I first became a GP.I am not sure that this was one of the conclusions of your contributors Gabbay and le May.Their paper expressed the obvious in such a way as to make it all but incomprehensible. Would it be possible to define EBM so as to make it both understandable and useful to clinicians, especially to GPs? What sort of evidence is admissable?What about clinical decisions taken when such evidence is unavailable? For the time being, I think that my patients would rather I carry on as before! Ed Stone, GP Bury, Lancs. Competing interests: None declared
Evidence based medicine in favor of biomedicine and it seems that holistic medicine has been forgotten? 11 November 2004
Søren Ventegodt, Medical director Quality of Life Research Center in Copenhagen, Teglgårdstræde 4-8, DK-1452 Copenhagen K, Denmark., Trine Flensborg-Madsen and Joav Merrick Send response to journal: Re: Evidence based medicine in favor of biomedicine and it seems that holistic medicine has been forgotten?	EDITOR---This communication in response to the recent editorial on evidence based medicine (EBM) by Straus and Jones (1). The present day state of the art of design, the double blind clinical trial, is in our opinion not the best methodological choice for evidence based medicine. Since Hippocrates it has been known that the curve of healing is a square curve, where the baseline of health, quality of life and ability is lifted to a new level during treatment (see figure in reference 2). If the curve is not square, the patient is not healed. It is fairly easy to take this fundamental insight in the healing of the patient into practical methodology, as we have done with the "square curve paradigm" (2) using the short questionnaires QOL1 (3,4) QOL5 (3,4) and WHOQOL (5). The beauty of this approach is that all branches of medicine can use the method to produce results. If there is a clinically significant effect it can be demonstrated with only 20 patients, which makes this method extremely fast and cheap. We have used this method to test the effect of alternative medicine on chronic whiplash associated disorder (chronic WAD) and found that the alternative treatment did not help the patients (5). The cost of that whole study was over 100.000 USD, because we also made a traditional randomisation and used a control group in order to adapt to international standards. The cost could have been reduced to a small fraction, if the square curve was generally accepted. To put it simply, only the pharmaceutical companies can afford the traditional kind of design, which leaves complementary and alternative medicine behind due to the cost involved. Additionally, the clinical double-blind trial is actually full of bias (6) making the "proved" effects less that completely proved. We therefore suggest to return to the simple way of documenting medicine: If the treatment is directly based on comprehensible scientific theory and the trial or treatment provide significant improvements in either QOL (Quality of Life) , health or ability when tested on 20 patients, we believe it is good evidence based medicine. If a treatment works without a good theory, it is still likely that we have a good physician, who can cause the treatment to work, but the effect can hardly be reproduced, because the treatment cannot be understood. This can still be labelled as good medical artwork, which is good for the patient - but not good enough for a scientific medical society. AFFILIATION Søren Ventegodt, MD, is a general practitioner and the director of the Quality of Life Research Center in Copenhagen, Denmark. E-mail: ventegodt@livskvalitet.org Website: www.livskvalitet.org/ Trine Flensborg-Madsen, MD, is a research assistant of the Quality of Life Research Center in Copenhagen, Denmark. She is at this time finishing her masters degree in Public Health at the Department of Public Health, University of Copenhagen. E-mail: tfm@livskvalitet.org Joav Merrick, MD, DMSc is professor of child health and human development, director of the National Institute of Child Health and Human Development and the medical director of the Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel. E-mail: jmerrick@internet-zahav.net. Website: www.nichd-israel.com REFERENCES 1. Straus SE, Jones G. What has evidence based medicine done for us? BMJ 2004;329:987-8. 2. Ventegodt S, Andersen NJ, Merrick J. Holistic Medicine II: The square-curve paradigm for research in alternative, complementary and holistic medicine: A cost-effective, easy and scientifically valid design for evidence based medicine. ScientificWorldJournal 2003;3; 1117-27. 3. Ventegodt S, Henneberg EW, Merrick J, Lindholt JS. Validation of Two Global and Generic Quality of Life Questionnaires for Population Screening: SCREENQOL and SEQOL. ScientificWorldJournal 2003;3;412-21. 4. Lindholt JS, Ventegodt S, Henneberg EW. Development and Validation of QoL5 for Clinical Databases. A Short, Global and Generic Questionnaire Based on an Integrated Theory of the Quality of Life. Eur J Surg; 2002;168;107-13. 5. Ventegodt S, Merrick J, AndersenNJ, Bendix T. A Combination of Gestalt Therapy, Rosen Body Work, and Cranio Sacral Therapy did not help in Chronic Whiplash-Associated Disorders (WAD) - Results of a Randomized Clinical Trial. Accepted by ScientificWorldJournal 2004. 6. Gøtzsches P. Bias in double-blind trials. Dan. Med. Bull 1990; 37; 329-336. Competing interests: None declared