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On December 17 2017 04:52 TheTenthDoc wrote: [quote]
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.
Do you think it's better policy to replace a malfunctioning paradigm with nothing? I still haven't heard a single solution from you, other than letting smart people like clinicians decide what to do based upon weighing the balance of the body of research.
Hmm. That sounds so much like the original EBM paradigm. Weird.
That said I now understand why you called that an assertion and italicized it. I am somewhat curious why you don't think hypothesis testing heavily drives the reproducibility crisis (especially since it's proveable that significance testing as a litmus for publication/meaning invariably biases non-null estimates), but that's not really a topic for this thread.
Clinicians (on average) aren't really all that good at determining the quality of evidence - it's one of the reasons why statistical significance still plagues the medical field. Don't get me wrong - clinicians are (on average) incredibly smart people. The issue is that only few are interested in statistics and thus the fetish behind RCT and p<0.05 has taken root.
I don't disagree, and that applies to far more than just doctors.
TheTenthDoc: I'm not suggesting there should be an alternate paradigm. I'm saying strict interpretations of EBM should not be encouraged right now. Which is essentially the same as just not mentioning EBM, as active promotion of EBM (or anything else) usually goes along with strict interpretations.
As far as hypothesis testing goes, you misunderstand me. I think null hypothesis significance testing does more harm than good in almost all cases. Like you, I'd much prefer to see clinical studies attempting to estimate effect size and to do away with the "uncertainty laundering" that significance is.
On December 16 2017 21:32 GreenHorizons wrote: Beyond blatant authoritarian bullshit, it's just shamefully stupid to ban the term "evidence-based".
That should alarm anyone even pretending to be remotely sensible.
If I was inclined to be generous I would think they're banning it because "evidence-based" is often a shortcut to picking out specific studies and ignoring the rest of the evidence. I'm not inclined to be generous though.
"Grounded in science", "Studies show" etc
In general though, that is absolutely retarded. I detested Harper in Canada when he muzzled all federal scientists, preventing them from speaking publicly without going through his PR agency. This is pretty much just as bad.
Could we soon see a Saturday Night Massacre redux? According to one prominent Democrat, that is the current scuttlebutt in Washington.
Speaking to California station KQED yesterday, Rep. Jackie Speier (D-CA) said that she is hearing rumors that President Donald Trump will fire Special Counsel Robert Mueller after Congress leaves for Christmas break.
“The rumor on the Hill when I left yesterday was that the president was going to make a significant speech at the end of next week,” Speier said. “And on December 22, when we are out of DC, he was going to fire Robert Mueller.” She stated that if Trump does indeed fire Mueller during the middle of his investigation of Russian election meddling and potential ties between the Trump campaign and Russian officials, that it would create a constitutional crisis. “Without a doubt, there would be an impeachment effort,” the House Intelligence Committee member exclaimed.
On December 17 2017 09:21 {CC}StealthBlue wrote: <Snip>
Trump has already commit Obstruction of justice once (Sure proving it in court is hard but Mueller is no idiot, he knows why Comey was fired) His close associates have lied multiple times about meetings and contacts.
Yes he is not going to not trust the Trumps to provide all data when asked.
On December 17 2017 09:21 {CC}StealthBlue wrote: <Snip>
Trump has already commit Obstruction of justice once (Sure proving it in court is hard but Mueller is no idiot, he knows why Comey was fired) His close associates have lied multiple times about meetings and contacts.
Yes he is not going to not trust the Trumps to provide all data when asked.
Still, better to snip in the bud Fox News' latest bit of excrement. They have their heads so far up Trump's ass watching them is like being in the Twilight Zone.
I'd have to look more closely at what documents that GSA had and why, but presuming that they are merely acting as a service provider and depending upon whether there was judicial approval of the seizure, there could be something to Trump's charge, including 4th Amendment issues and issues of attorney/prosecutor ethics.
we shall see if/when it comes before a court; but until then there's no reason to give any credence to a trump charge. and plenty of reason to give credence to mueller.
Supports why Jared Kushner is looking for PR-firms. He's fucked.
On December 17 2017 09:43 xDaunt wrote: I'd have to look more closely at what documents that GSA had and why, but presuming that they are merely acting as a service provider and depending upon whether there was judicial approval of the seizure, there could be something to Trump's charge, including 4th Amendment issues and issues of attorney/prosecutor ethics.
LOL. Please look closely. If they're claiming privilege on them, I'm sure the e-mails contain some wonderful material that we'd all like to see.
I think the best way to keep Trump from firing Mueller is probably to have the mainstream media continually report he's considering firing Mueller (or firing him by proxy). He doesn't want to make any of their stories look true if he can help it.
The saddest part is, people will actually think it's justified even though it is factual that many people interviewed by the council lied and got caught out, including high ranking members.
As a sidenote, Mueller is a former deputy attorney general, director of the FBI (as a bonus, nominated by a republican president), and worked for almost 30 years in the law field. I'm pretty convinced he knows what he's doing and wouldn't make a mistake that is a major plotpoint every second law and order episode.
EPT
