Rebuttal of Con: Should Evidence-Based Medicine Be Used More in Clinical Practice?
Notice bibliographique
Résumé
The California Journal of Emergency Medicine VII:1, Jan-Mar, 2006 Page 19 REFERENCES 1. Wolfe JM et al. Does morphine change the physical examination in patients with acute appendicitis? American Journal of Emergency Medicine 2. Thomas SH et al. Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: a prospective randomized trial. Journal of American College of Surgeons 3. LoVecchio F et al. The use of analgesic in patients with acute abdominal pain. Journal of Emergency Medicine 1997;15:775-779. 4. Vernculen B et al. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate—a randomized trial. Radiology 1999;210:639-643. 5. Evidence-Based Medicine Working Group, “Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992;268:2420-2425. 6. Haydel M et al. Indication for computed tomography in patients with minor head injury. New England Journal of Medicine 2000;343:100-105. 7. Stiell IG et al. The Canadian CT head rule for patients with minor head injury. Lancet 2001;357:1391- Rebuttal of Con Chris Fee, MD After reading both opening pieces, I am struck more by the similarities in our attitudes toward increasing the utilization of EBM in clinical practice than our differences. We do differ in our opinions of the utility of clinical experience and common sense (“plausible theorizing”). There are innumerable examples of how dangerous this approach to medicine can be. One could, through common sense and pathophysiologic knowledge, conclude that chest pain that does not resolve with nitroglycerine but subsides with administration of Maalox cannot be cardiac, but is likely to have a gastrointestinal etiology. Many of our differences can be explained by failing to acknowledge the complete definition of EBM. Recall the full definition: “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” 1 This does not imply that every medical decision must be supported by a RCT or meta-analysis. Clearly, not all clinical issues are significant enough to warrant a RCT. Many decisions necessitate the use of “current best” available evidence. If a clinical scenario exists that occurs frequently, presents sufficient risk to patients, and has no clear best approach, perhaps a study should be conducted. All it takes is a clinician/ researcher with the interest, time, training, and resources. Other clinical questions will never be examined by a RCT due to ethical concerns, consent issues, or rarity of the event/illness. Thus, many of our patients do receive care based upon “soft” evidence (the “best available” evidence). But do we truly know that “soft” evidence improves care of our patients, as my colleague states? The beauty of EBM is its dynamic nature and ability to evolve and incorporate new data as it becomes available. As we amass more information with time, we will have fewer clinical quandaries and less reliance upon “soft” evidence. Every emergency physician understands the importance of throughput. However, this should not supercede providing appropriate care. EBM is rife with decision rules aimed at meeting both of these goals: the Ottawa foot, ankle, and knee rules, the Nexus and Canadian C-spine rules, Wells criteria for pre-test probability of deep venous thrombosis, and the Pneumonia Severity Index score to name a few. Correctly applying these rules may safely increase throughput by avoiding unnecessary tests and admissions. My colleague unintentionally highlights another tremendously important component of EBM: one must know how to read, interpret, critique, and apply the literature. Is the study’s data internally consistent? Were the groups truly randomized? Were the statistical tools correctly applied and performed? Are the conclusions appropriate? These questions evaluate a study’s internal validity. The generalizability (or external validity) of a study must be assessed with
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,017 | 0,171 |
| Méta-épidémiologie (sens strict) | 0,002 | 0,001 |
| Méta-épidémiologie (sens large) | 0,003 | 0,002 |
| Bibliométrie | 0,003 | 0,003 |
| Études des sciences et des technologies | 0,005 | 0,011 |
| Communication savante | 0,013 | 0,013 |
| Science ouverte | 0,007 | 0,006 |
| Intégrité de la recherche | 0,044 | 0,061 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,036 | 0,039 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».