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Read the rules in the OP before posting, please.In order to ensure that this thread continues to meet TL standards and follows the proper guidelines, we will be enforcing the rules in the OP more strictly. Be sure to give them a re-read to refresh your memory! The vast majority of you are contributing in a healthy way, keep it up! NOTE: When providing a source, explain why you feel it is relevant and what purpose it adds to the discussion if it's not obvious. Also take note that unsubstantiated tweets/posts meant only to rekindle old arguments can result in a mod action. |
On December 17 2017 06:04 Nevuk wrote:Show nested quote +On December 17 2017 05:49 {CC}StealthBlue wrote:
The CDC story is now being overshadowed by the NYT story on Harry Reid. I'll admit it is a WTF story. Also where is Travis?
He should be here right now regarding said story. I think it's conclusive evidence that the government doesn't know shit about UFOs
$110 million dollars over 5 years isn't chump change. Now imagine if the program is still active.
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On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point.
Forgive me for asking but what is your background? And who is it exactly you consider "the most respected statisticians in the field"?
EDIT: I think you linked to the wrong wiki-article. Here is the article for EBM:
https://en.wikipedia.org/wiki/Evidence-based_medicine
You'll notice that it doesn't exactly line up with your definition of evidence-based.
EDIT2: I think the part of EBM that is contested is mostly the hierarchy of studies. I think you are going to be hard-pressed to find anyone who actually considers it detrimental to strive for EBM at a basic level - i.e. that clinical decision-making rests on a foundation of evidence.
EDIT3: What do you mean by "low quality of most published medical studies"? Are you talking about the reproducibility? Fragility-index? Or something else?
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On December 17 2017 05:55 zlefin wrote:
mozoku -> yeah, you have no good argument, as expected, nor do you own up to the amply pointed out problems with your prior ones.
there's a difference between opposing those things, and forbidding an arm of the government from mentioning them in its budget; especially seeing as some of those thins are rather important and undre its purview.
it is orwellian, and you're unable to see you're bein ga partisan shill for it. such is the sadness of these days.
it's not HIS budget; it's the budget of the CDC, acting on behalf of the american people.
danglars -> who is that person and why should I care about their opinion on the matter?
especially seeing as they don' tlink to any facts, so all that is provided is their own opinion.
On December 15 2017 12:05 zlefin wrote:
a non-answer, i'll take that as a your being intentionally disingenuous to cover for your blatant partisan hackery.
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On December 17 2017 06:24 Danglars wrote:Show nested quote +On December 17 2017 05:55 zlefin wrote:
mozoku -> yeah, you have no good argument, as expected, nor do you own up to the amply pointed out problems with your prior ones.
there's a difference between opposing those things, and forbidding an arm of the government from mentioning them in its budget; especially seeing as some of those thins are rather important and undre its purview.
it is orwellian, and you're unable to see you're bein ga partisan shill for it. such is the sadness of these days.
it's not HIS budget; it's the budget of the CDC, acting on behalf of the american people.
danglars -> who is that person and why should I care about their opinion on the matter?
especially seeing as they don' tlink to any facts, so all that is provided is their own opinion. Show nested quote +On December 15 2017 12:05 zlefin wrote:
a non-answer, i'll take that as a your being intentionally disingenuous to cover for your blatant partisan hackery.
I asked a reasonable question, and you do this.
so you have nothing and are intentionally trolling, got it.
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On December 17 2017 05:55 Danglars wrote:
It's well and good to say that, but still does nothing to advance its claim. If you want to post a link actually showing that it's faulty, go ahead. If word of mouth sufficed to discredit a report, I would've been happy with the HHS take.
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On December 17 2017 06:29 NewSunshine wrote:It's well and good to say that, but still does nothing to advance its claim. If you want to post a link actually showing that it's faulty, go ahead. If word of mouth sufficed to discredit a report, I would've been happy with the HHS take.
I'm almost positive that tweet is just referring to the HHS statement. Kind of like how an MSNBC interview became reports of a history of supporting full-birth abortion (or if you prefer a more conservative example how a 2000 Pence statement became heavy support of gay conversion therapy).
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On December 17 2017 06:32 TheTenthDoc wrote:Show nested quote +On December 17 2017 06:29 NewSunshine wrote:It's well and good to say that, but still does nothing to advance its claim. If you want to post a link actually showing that it's faulty, go ahead. If word of mouth sufficed to discredit a report, I would've been happy with the HHS take. I'm almost positive that tweet is just referring to the HHS statement. Kind of like how an MSNBC interview became reports of a history of supporting full-birth abortion (or if you prefer a more conservative example how a 2000 Pence statement became heavy support of gay conversion therapy).
Exactly. Here's the thing: I'm really not opposed to being wrong about whether this is a big deal. I would much rather it be a non-story. But all I'm seeing that contradicts it is word of mouth. If another report surfaced that clarifies what went down and illustrates why it's not a big deal, I'm on board with that. But until then, it looks like a big deal. One of many out of this administration, but still. Simply saying it didn't happen doesn't make it true.
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On December 17 2017 06:06 TheTenthDoc wrote:Show nested quote +On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one.
More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process.
Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't.
On December 17 2017 05:55 zlefin wrote:
mozoku -> yeah, you have no good argument, as expected, nor do you own up to the amply pointed out problems with your prior ones.
there's a difference between opposing those things, and forbidding an arm of the government from mentioning them in its budget; especially seeing as some of those thins are rather important and undre its purview.
it is orwellian, and you're unable to see you're bein ga partisan shill for it. such is the sadness of these days.
it's not HIS budget; it's the budget of the CDC, acting on behalf of the american people.
Another Zlefin post that is utterly devoid of substance and does no more than proclaim those he disagrees with as disingenuous and wrong. Color me shocked.
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New evacuation orders were issued on Saturday in Santa Barbara County, California, as wind gusts up to 60mph pushed the third-largest wildfire in state history towards a wealthy enclave which is home to Oprah Winfrey and other celebrities.
The mandatory evacuation zone was increased to 17 miles long and up to five miles wide, extending from coastal mountains north-west of Los Angeles to the ocean.
One firefighter was killed on Thursday. The Ventura County medical examiner announced autopsy results on Saturday for Cory Iverson, 32, who died from burns and smoke inhalation on the eastern flank of the Thomas blaze, in canyons near the agricultural town of Fillmore. No other details were released.
Iverson’s death was a stunning blow to those fighting the flames.
“When that happened, this fire hit a whole new level because all the firefighters know that could have been them,” said Steve Concialdi of the Orange County Fire Authority. “When you lose a fellow brother, that hits all of us and our families extremely hard.”
The fire was also was blamed for the death last week of a 70-year-old woman who died in a car crash on an evacuation route.
The Thomas fire began on 4 December in Santa Paula and has burned a record acreage, officials said on Saturday. Concialdi said the Thomas fire had burned 2,000 acres more than the devastating Rim Fire of 2013.
“As of this morning, we’re at 259,000 acres and still growing,” Concialdi said.
The region has had “red flag” or hot, dry and windy conditions for an unprecedented 13 consecutive days. The National Weather Service (NWS) said those conditions would last at least through Saturday evening.
Santa Barbara has had only a tiny amount of rain since 1 October, the start of the new water year, and is more than 3in (7.6cm) below normal to date.
Everything about the fire is massive, from a footprint larger than that of many cities to the sheer scale of destruction that has cremated entire neighborhoods to the legions attacking it. About 8,300 firefighters from nearly a dozen states have been aided by 78 bulldozers and 29 helicopters dropping thousands of gallons of water. Firefighting costs are approaching $89m.
The fire in Ventura and Santa Barbara counties has burned more than 1,000 buildings, including more than 750 homes. Another 18,000 buildings are still in jeopardy, including mansions in the wealthy enclave of Montecito.
Some 315 fire engines were stationed in and around homes in Montecito and Santa Barbara on Saturday, along with “hand crews” armed with equipment like chain saws and drop torches. Another 200 fire engines were on standby. Concialdi said authorities were hoping to have the blaze contained by 7 January.
Source
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On December 17 2017 06:46 mozoku wrote:Show nested quote +On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't.
But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some type of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good?
What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit.
The lack of estimation-based research (which is the heart of the reproducibility problem and publication bias) has absolutely nothing to do with whether we have the CDC using the words "evidence-based" in budget documents.
Edit: Acting based upon well-conducted evidence and ignoring non-credible evidence (the heart of EBM) doesn't make you a slave. It makes you a rational actor.
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On December 17 2017 06:25 zlefin wrote:Show nested quote +On December 17 2017 06:24 Danglars wrote:On December 17 2017 05:55 zlefin wrote:
mozoku -> yeah, you have no good argument, as expected, nor do you own up to the amply pointed out problems with your prior ones.
there's a difference between opposing those things, and forbidding an arm of the government from mentioning them in its budget; especially seeing as some of those thins are rather important and undre its purview.
it is orwellian, and you're unable to see you're bein ga partisan shill for it. such is the sadness of these days.
it's not HIS budget; it's the budget of the CDC, acting on behalf of the american people.
danglars -> who is that person and why should I care about their opinion on the matter?
especially seeing as they don' tlink to any facts, so all that is provided is their own opinion. On December 15 2017 12:05 zlefin wrote:
a non-answer, i'll take that as a your being intentionally disingenuous to cover for your blatant partisan hackery. I asked a reasonable question, and you do this. so you have nothing and are intentionally trolling, got it.
On December 06 2017 09:58 zlefin wrote:
just as I said, we can't expect sense from people. ah, the damage caused to the world due to people's wrong and unjustified beliefs.
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On December 17 2017 06:53 TheTenthDoc wrote:Show nested quote +On December 17 2017 06:46 mozoku wrote:On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't. But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some time of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good? What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit.
I don't think he is arguing against the application of evidence in medicine. I think he is arguing against only practicing medicine based on scientific studies/current knowledge (i.e. refrain from offering any treatment if it hasn't been proven efficacious in an RCT - e.g. pain-treatment of fibromyalgia with gabapentin). I have yet to meet anyone who is a evidence-purist to that degree (and I was taught by Peter C Gøtzsche in medical school who is probably one of the biggest evidence-purists out there).
EDIT: Funny story in relation to EBM: There has never actually been an RCT demonstrating the association between tobacco and cancer - so if you were a purist you would insist that no high-quality evidence exists. However, I have yet to meet anyone who doesn't acknowledges the causal link which has been established purely on observational data.
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On December 17 2017 07:01 Ghostcom wrote:Show nested quote +On December 17 2017 06:53 TheTenthDoc wrote:On December 17 2017 06:46 mozoku wrote:On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't. But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some time of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good? What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit. I don't think he is arguing against the application of evidence in medicine. I think he is arguing against only practicing medicine based on scientific studies/current knowledge (i.e. refrain from offering any treatment if it hasn't been proven efficacious in an RCT - e.g. pain-treatment of fibromyalgia with gabapentin). I have yet to meet anyone who is a evidence-purist to that degree (and I was taught by Peter C Gøtzsche in medical school who is probably one of the biggest evidence-purists out there).
What you say is, on its own, totally reasonable and makes sense. Not arguing there.
However this is no way, nor does anything mozuko has said, justify or defend the accusation of the WaPo article.
This perspective doesn't not at all explain why the CDC would be "advised" against using the term EBM in their report. Even if a methodology is dubious, removing the term from the discussion is... strange at generous best.
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On December 17 2017 07:01 Ghostcom wrote:Show nested quote +On December 17 2017 06:53 TheTenthDoc wrote:On December 17 2017 06:46 mozoku wrote:On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't. But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some time of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good? What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit. I don't think he is arguing against the application of evidence in medicine. I think he is arguing against only practicing medicine based on scientific studies/current knowledge (i.e. refrain from offering any treatment if it hasn't been proven efficacious in an RCT - e.g. pain-treatment of fibromyalgia with gabapentin). I have yet to meet anyone who is a evidence-purist to that degree (and I was taught by Peter C Gøtzsche in medical school who is probably one of the biggest evidence-purists out there). EDIT: Funny story in relation to EBM: There has never actually been an RCT demonstrating the association between tobacco and cancer - so if you were a purist you would insist that no high-quality evidence exists. However, I have yet to meet anyone who doesn't acknowledges the causal link which has been established purely on observational data.
But being an RCT purist and a diehard "only p <0.05 means anything" doesn't have to do with evidence-based medicine. After all, the love for and obsession with RCTs predated EBM as a term by a while (and it will probably outlive it). Dispensing gabapentin for nerve pain is still based on quality evidence, just like (a lot) of off-label prescribing is (with the remainder being unfortunately based on low quality evidence *cough metformin better not ever be off-label for cancer prevention cough*).
If the CDC stopped using "pyramid of evidence" I would be all for it though. Well, they're allowed to use it to say "the pyramid of evidence is a stupid idea."
(Fun tidbit: there are still a couple folks out there that will insist the smoking-cancer link isn't causal because of the above psychotic reliance on internal validity. One from 1999. I think a lot of them literally died out, though)
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On December 17 2017 07:15 TheTenthDoc wrote:Show nested quote +On December 17 2017 07:01 Ghostcom wrote:On December 17 2017 06:53 TheTenthDoc wrote:On December 17 2017 06:46 mozoku wrote:On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't. But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some time of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good? What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit. I don't think he is arguing against the application of evidence in medicine. I think he is arguing against only practicing medicine based on scientific studies/current knowledge (i.e. refrain from offering any treatment if it hasn't been proven efficacious in an RCT - e.g. pain-treatment of fibromyalgia with gabapentin). I have yet to meet anyone who is a evidence-purist to that degree (and I was taught by Peter C Gøtzsche in medical school who is probably one of the biggest evidence-purists out there). EDIT: Funny story in relation to EBM: There has never actually been an RCT demonstrating the association between tobacco and cancer - so if you were a purist you would insist that no high-quality evidence exists. However, I have yet to meet anyone who doesn't acknowledges the causal link which has been established purely on observational data. But being an RCT purist and a diehard "only p <0.05 means anything" doesn't have to do with evidence-based medicine. After all, the love for and obsession with RCTs predated EBM as a term by a while (and it will probably outlive it). Dispensing gabapentin for nerve pain is still based on quality evidence, just like (a lot) of off-label prescribing is (with the remainder being unfortunately based on low quality evidence). (Fun tidbit: there are still a couple folks out there that will insist the smoking-cancer link isn't causal because of the above psychotic reliance on internal validity. One from 1999)
I fully agree with you. And the sooner we kill off statistical significance, the better off we will be.
EDIT: And yes, pyramid of evidence, and the hierarchy needs to go ASAP as well.
EDIT2: Regarding gabapentin for fibromyalgia: I believe this is the latest Cochrane review on the topic. As you'll note the conclusion is that the evidence is of low quality. Neuropathic pain is a different story.
https://www.ncbi.nlm.nih.gov/pubmed/28045473
On December 17 2017 07:13 Ciaus_Dronu wrote:Show nested quote +On December 17 2017 07:01 Ghostcom wrote:On December 17 2017 06:53 TheTenthDoc wrote:On December 17 2017 06:46 mozoku wrote:On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't. But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some time of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good? What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit. I don't think he is arguing against the application of evidence in medicine. I think he is arguing against only practicing medicine based on scientific studies/current knowledge (i.e. refrain from offering any treatment if it hasn't been proven efficacious in an RCT - e.g. pain-treatment of fibromyalgia with gabapentin). I have yet to meet anyone who is a evidence-purist to that degree (and I was taught by Peter C Gøtzsche in medical school who is probably one of the biggest evidence-purists out there). What you say is, on its own, totally reasonable and makes sense. Not arguing there. However this is no way, nor does anything mozuko has said, justify or defend the accusation of the WaPo article. This perspective doesn't not at all explain why the CDC would be "advised" against using the term EBM in their report. Even if a methodology is dubious, removing the term from the discussion is... strange at generous best.
I fully agree.
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On December 17 2017 06:53 TheTenthDoc wrote:Show nested quote +On December 17 2017 06:46 mozoku wrote:On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't. But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some type of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good? What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit. The lack of estimation-based research (which is the heart of the reproducibility problem and publication bias) has absolutely nothing to do with whether we have the CDC using the words "evidence-based" in budget documents.Edit: Acting based upon well-conducted evidence and ignoring non-credible evidence (the heart of EBM) doesn't make you a slave. It makes you a rational actor.
I never discredited properly performed science, so I don't know why you're trying to convince me science is a good thing. That has nothing to do with my point.
The italicized is merely an assertion on your part. There's perfectly good reasons to be not promoting EBM in the way the term is actually understood by medical community (i.e. rigid adherence to literature). To be honest, Trump's motivations aren't even that relevant imo because it'll lead to better patient care (at present) and Trump's supposed anti-science agenda and presidency is likely going to be gone by the time the replication crisis sorts itself out.
As for the bold, it's like you're purposely ignoring that a huge section of the literature is flawed. EBM literally requires a evidential basis for treatment. When the "evidence" is defined as published research (as it is in practice), you're required to follow whatever it says. This isn't complicated. I don't know what definitional shift you're trying to pull here by claiming "evidence-based medicine" means you can disregard what it (incorrectly) defines as "evidence."
Here's another way to look at it: most medical basis on the present age doesn't meet "evidence-based" standards. Given that the literature is currently a bit of a mess, there's no reason to be taking about evidence-based medicine in budgets. That requires zero political anti-science agenda, which aligns with my belief that Trump doesn't know what EBM is.
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On December 17 2017 07:24 mozoku wrote:Show nested quote +On December 17 2017 06:53 TheTenthDoc wrote:On December 17 2017 06:46 mozoku wrote:On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't. But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some type of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good? What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit. The lack of estimation-based research (which is the heart of the reproducibility problem and publication bias) has absolutely nothing to do with whether we have the CDC using the words "evidence-based" in budget documents.Edit: Acting based upon well-conducted evidence and ignoring non-credible evidence (the heart of EBM) doesn't make you a slave. It makes you a rational actor. I never discredited properly performed science, so I don't know why you're trying to convince me science is a good thing. That has nothing to do with my point. The italicized is merely an assertion on your part. There's perfectly good reasons to be not promoting EBM in the way the term is actually understood by medical community (i.e. rigid adherence to literature). To be honest, Trump's motivations aren't even that relevant imo because it'll lead to better patient care (at present) and Trump's supposed anti-science agenda and presidency is likely going to be gone by the time the replication crisis sorts itself out. As for the bold, it's like you're purposely ignoring that a huge section of the literature is flawed. EBM literally requires a evidential basis for treatment. When the "evidence" is defined as published research (as it is in practice), you're required to follow whatever it says. This isn't complicated. I don't know what definitional shift you're trying to pull here by claiming "evidence-based medicine" means you can disregard what it (incorrectly) defines as "evidence."
Seriously, are you actually part of the medical community? Because the more you write, the less it seem so. And it seems like you have fundamentally misunderstood EBM.
EDIT: To be crystal clear: EBM doesn't require evidence before treatment. EBM as a paradigm means that we should strive towards there being evidence for all treatments - and that treatment which has proven efficacious should superseede treatments which haven't. The difference is important.
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On December 17 2017 07:24 mozoku wrote:Show nested quote +On December 17 2017 06:53 TheTenthDoc wrote:On December 17 2017 06:46 mozoku wrote:On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't. But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some type of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good? What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit. The lack of estimation-based research (which is the heart of the reproducibility problem and publication bias) has absolutely nothing to do with whether we have the CDC using the words "evidence-based" in budget documents.Edit: Acting based upon well-conducted evidence and ignoring non-credible evidence (the heart of EBM) doesn't make you a slave. It makes you a rational actor. I never discredited properly performed science, so I don't know why you're trying to convince me science is a good thing. That has nothing to do with my point. The italicized is merely an assertion on your part. There's perfectly good reasons to be not promoting EBM in the way the term is actually understood by medical community (i.e. rigid adherence to literature). To be honest, Trump's motivations aren't even that relevant imo because it'll lead to better patient care (at present) and Trump's supposed anti-science agenda and presidency is likely going to be gone by the time the replication crisis sorts itself out. As for the bold, it's like you're purposely ignoring that a huge section of the literature is flawed. EBM literally requires a evidential basis for treatment. When the "evidence" is defined as published research (as it is in practice), you're required to follow whatever it says. This isn't complicated. I don't know what definitional shift you're trying to pull here by claiming "evidence-based medicine" means you can disregard what it (incorrectly) defines as "evidence."
You are throwing out a paradigm for a nebulous shift to "not that paradigm" when what you should be doing is forcing the makers of the paradigm to actually adhere to the paradigm. Just as the person you cited said you should. Your problem seems to be not with the EBM paradigm in concept, but in execution.
That's what I have an issue with in your posts here. "Rigid adherence to the literature" (a.k.a. using the literature to guide your medical practice rather than expert opinion) is only a problem if the literature is poorly constructed and evaluated improperly, which is not an inevitability (well, I'll "assert" that it is an inevitability under absurd statistical testing frameworks, but that will hopefully die soon).
A tidbit: this meeting also actually specifically banned "science-based" as well, if it's to be believed.
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On December 17 2017 07:31 TheTenthDoc wrote:Show nested quote +On December 17 2017 07:24 mozoku wrote:On December 17 2017 06:53 TheTenthDoc wrote:On December 17 2017 06:46 mozoku wrote:On December 17 2017 06:06 TheTenthDoc wrote:On December 17 2017 05:59 mozoku wrote:On December 17 2017 05:23 TheTenthDoc wrote:On December 17 2017 05:14 mozoku wrote:On December 17 2017 04:52 TheTenthDoc wrote:On December 17 2017 04:01 mozoku wrote:"Evidence-based" and "science-based" in the medical field is a very specific term that describes a decision making process that is essentially requires a study for any clinical decision and EBM (evidence-based medicine) has been under criticism for a while by some of the most well-respected statisticians in the field in part because of the low quality of most published medical studies. This actually has nothing to do with Orwellian-ism and everyone to do with your guys' ignorance. Doctors that don't practice EBM (which is most of them I believe) aren't doing exorcisms, they just don't require a published study for every decision. In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. Evidence-based medicineCriticismThis is definitely not a thread high-point. I would agree with you if the far worse "expert opinion" wasn't the only alternative to "evidence-based" medicine. The solution to poor studies isn't to not be evidence based, it's to actually have good studies. "Expert opinion" tends to be just "practitioner n of 1" studies writ large, which are one of the major problems plaguing medicine. Expert opinion was behind years of deleterious prostate cancer screening. You clearly don't understand what EBM actually is and what the problems with it are. Read the links again. I actually do? I work in the field. I made decisions for patients based on clinical evidence. From your first link: "Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research." Please explain to me what you prefer to this paradigm. I take issue with the specifics (particularly the hierarchical approach to evidence) but this is a problem throughout medicine even outside this paradigm, independent of making decision using evidence from well-designed and well-conducted research. Show me an alternative paradigm that isn't expert opinion. Please. In fact, the problems of evidence-based medicine's implementation are when expert opinion is allowed to creep in to form the hierarchy. Edit: for fuck's sake, your second link even says it's a worthy goal to be obtained but has been hijacked! The solution to hijacking isn't just to make a new identical thing up! That's how you get stupidity like "real-world medicine" and "comparative effectiveness research" being "new" terms when they've been studied for decades, if not century. To your edit, I literally acknowledged the same thing: In theory, EBM is a good idea but in practice it doesn't work out so well for various reasons. The issue with EBM isn't the fact that it uses evidence, obviously. Its name is about as accurate as the name of the average congressional act. The issue is that, in practice, it precludes a practitioner from pursuing treatment options outside of the literature. And the literature is a) not comprehensive, b) often flawed as medical studies are usually badly underpowered, and c) distorted by the incentives that EBM creates. So wouldn't you want the CDC to be able to say "this funding announcement is to expand the literature base to enhance the quality of evidence-based medicine?" Going outside the "literature" is a great way to end up in the land of Doctor Oz. And has even worse financial incentives for many treatments-"expert opinion" is a lot easier to buy than a study, even a poorly done one. More funding is the last thing that's going to fix the problems in the medical literature, so no. What it needs is to fix its publication process. Your worship of the literature made sense in 2000 (before the problems with it were widely known). I'm not sure where you've been living for the past few years where you still think its still justified. You can more easily end up in the Land of Doctor Oz by blindly following the literature (as EBM tells you do to) than you can by being a smart human being (as doctors usually are) and using professional judgment. Doctors who don't adhere to EBM should still be reading the literature and applying it when appropriate. The key difference is that they aren't enslaved to whatever it says--which is demonstrably often not replicable. Doctors, like every other professional, are subject to audits and reviews to make sure their practice is reasonable. You act like the literature is the only safeguard here, when it clearly isn't. But what is your basis for auditing and reviews to make sure they're reasonable? Surely you're talking about some type of evidence? "Smart human beings" bloodlet people for centuries. Why do you think that is? Do you think they were doing so because they had trials showing bloodletting was good? What did it take to understand the transmission of cholera? Literature. Why did we start using clean room techniques? Observational and randomized studies showing tremendous benefit. The lack of estimation-based research (which is the heart of the reproducibility problem and publication bias) has absolutely nothing to do with whether we have the CDC using the words "evidence-based" in budget documents.Edit: Acting based upon well-conducted evidence and ignoring non-credible evidence (the heart of EBM) doesn't make you a slave. It makes you a rational actor. I never discredited properly performed science, so I don't know why you're trying to convince me science is a good thing. That has nothing to do with my point. The italicized is merely an assertion on your part. There's perfectly good reasons to be not promoting EBM in the way the term is actually understood by medical community (i.e. rigid adherence to literature). To be honest, Trump's motivations aren't even that relevant imo because it'll lead to better patient care (at present) and Trump's supposed anti-science agenda and presidency is likely going to be gone by the time the replication crisis sorts itself out. As for the bold, it's like you're purposely ignoring that a huge section of the literature is flawed. EBM literally requires a evidential basis for treatment. When the "evidence" is defined as published research (as it is in practice), you're required to follow whatever it says. This isn't complicated. I don't know what definitional shift you're trying to pull here by claiming "evidence-based medicine" means you can disregard what it (incorrectly) defines as "evidence." You are throwing out a paradigm for a nebulous shift to "not that paradigm" when what you should be doing is forcing the makers of the paradigm to actually adhere to the paradigm. Just as the person you cited said you should. Your problem seems to be not with the EBM paradigm in concept, but in execution. That's what I have an issue with in your posts here. "Rigid adherence to the literature" (a.k.a. using the literature to guide your medical practice rather than expert opinion) is only a problem if the literature is poorly constructed and evaluated improperly, which is not an inevitability (well, I'll "assert" that it is an inevitability under absurd statistical testing frameworks, but that will hopefully die soon). A tidbit: this meeting also actually specifically banned "science-based" as well, if it's to be believed.
Good policy promotes adherence to a paradigm when it actually works, not when it's currently broken and only might be fixed in the future. There's people actually affected by this. I'm questioning whether science is a religion or a way of helping people to you.
"Science-based" is literally a synonym for "evidence-based" btw. A Wikipedia search for each term even redirects to the same place.
As for Ghostcom: I'm not in the medical community per se, but I'm a statistician that has studied the replication crisis and medical publication process.
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EPT
