firecat

This essay basically says (my own words) "In our enthusiasm for evidence-based medicine (which uses statistics and large population samples to evaluate treatments and create clinical guidelines), let's make sure not to throw out things doctors learn through many years of practice seeing one patient at a time." It says it really, really well.

"Why do we always end up here? Evidence-based medicine’s conceptual cul-de-sacs and some off-road alternative routes" by Trisha Greenhalgh, M.D. (Journal of Primary Health Care 2012; 4(2))

Excerpts:

Researchers in dominant paradigms tend to be very keen on procedure. They set up committees to define and police the rules of their paradigm, awarding grants and accolades to those who follow those rules. This entirely circular exercise works very well just after the establishment of a new paradigm, since building systematically on what has gone before is an efficient and effective route to scientific progress. But once new discoveries have stretched the paradigm to its limits, these same rules and procedures become counterproductive and constraining. That’s what I mean by conceptual cul-de-sacs.
...
the skilled practice of medicine is not merely about knowing the rules, but about deciding which rule is most relevant. This remains under-acknowledged and undertheorised in the dominant EBM paradigm. Illness may be a narrative, but just as in law, just as in literature, there is no text that is self-interpreting.
...
I think something sinister is happening, mainly because of the striking circumstantial resonance between the reductionism of EBM and the reductionism of contemporary policymaking.
...
EBM isn’t inherently wrong, but it plays to a vision of science that is characterised by predictive certainty—a vision that is taught to schoolchildren and perpetuated in the media, a vision of simple logic with readily deduced details and rule-governed consequences. It is this logic, coupled with the values of consumerism, which appear to have prompted the coalition government to develop a one-dimensional metric of human happiness which will light up like a thermometer bulb when policy tickles the public G-spot.

These books that she mentions sound very interesting:
How Doctors Think by Kathryn Montgomery (not the book of the same name by Jerome Groopman)
Complex Knowledge by Professor Hari Tsoukas
Upheavals of Thought: The Intelligence of Emotions by Martha Nussbaum
The Logic of Care by Annemarie Mol

Crossposts: http://firecat.livejournal.com/800433.html

Flat | Top-Level Comments Only

From:

shehasathree

Love Trisha Greenhalgh, and love the Kathryn Montgomery book. I immediately thought of it upon reading the first few lines you quoted above. :)

Thank-you for sharing!

From:

ysabetwordsmith

What this means is that if your body is
not in the middle of the bell curve, you either gamble on care that could be worse
than useless, or you get no medical care
at all, because the chance of finding
anyone willing to deal with your actual
body instead of a textbook mirage approaches nil.

From:

megpie71

Not just your body. If you happen to be mentally outlying on the bell curve, you're going to be getting less than optimum care. I combine being an outlier on the intellectual side ("academically gifted and talented" was the terminology they used while I was in school) with being an outlier on the mental illness side (chronic depression, comorbid anxiety issues). The combination of the two means I've never yet run across a GP who's been willing to actually listen to what I'm saying rather than what their textbook appears to be dictating for me.

End result? I don't bother the GPs unless there's an actual physical problem to be treated, like a cold or flu. Otherwise, it really isn't worth the hassle.

From:

ysabetwordsmith

>>Not just your body. If you happen to be mentally outlying on the bell curve, you're going to be getting less than optimum
care.<<

Agreed. I was aware of that problem too, just didn't think to include it in my earlier comment.

>>I don't bother the GPs unless there's an actual physical problem to be treated, like a cold or flu. Otherwise, it really isn't worth the hassle.<<

I only go if there is:

* a specific complaint that I already know how to define and solve, just needs materials I can't readily access on my own. This has a moderate rate of success.

* a specific complaint that I can define but don't know how to fix. This has a low rate of success.

I don't bother if I can't be specific. That never gets solved no matter how bad it is. I also don't bother if the situation is at all tolerable, and that bar has been rising. The last failout actually bumped it above "I think this might possibly kill me."

The system is so distorted that there is very little it's willing and able to do for me, that I'm willing and able to put up with, that might actually be useful. That's frustrating.