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Sun Jul 11 03:36:51 BST 2004

In regards with the specific case, the evidence is that there is no
evidence. Little is known about the neurovascular field in general, and
less in the specifics of the posterior circulation.

In relation with the evidence you provide I do not say that is not valid.
I say it is far from sufficient and as presented is not suited to address
or take it as the answer for such cases.

Regarding the evidence based medicine, you should be aware that if you are
going to relay on it to take decisions, you will find that an important
amount of what it is done has no evidence, or it is weak, or, furthermore,
found later to be wrong.

Additionally, the medical based evidence gives some answers and has its
limitation. My concern is not the virtues of such data, but the impact of
its weaknesses. Although that the present concept of medical evidence is
the only tool we have to direct our decisions we have to have clear that
it is not the ultimate source of truth for patient management.

In the Neurological  population it is needed to improve the type and
recollection of information bedside, in real time to direct treatments,
optimize , and evaluate their effects. We have to treat tissue with the
type,amount and length of treatment that tissue needs.

There are many essays, experiences and events to recall... ...
remember that some years ago the earth was flat and the soul was in the
center of the chest... the first found to be wrong, and the second is
still a mystery.

The last one, from my own:

what we know is not what defines the outcome or destiny of a problem. The
key is what we do not know. This missing part shapes what we take today as
an absolute or as a valid information, always imperfect and able to be
improved.

May be I am not fear with you. The evidence is always there if we take the
effort of looking for it (more than an effort a commitment). There is
something that is not written yet, many things that have influence in the
management of patients and are not known so far. This is in the experience
of certain physicians, so far the only resource to compensate the
imperfections of what we do based on an imperfect system. Probably I am
expecting from MDs like you to tell not the evidence we can find if we
know how to read, but the potential land-mines of today's medical
information.

JM

> In a message dated 7/10/2004 5:13:04 PM Eastern Standard Time,
> DocRickFry at aol.com writes:
>
> In a message dated 7/10/2004  2:32:08 PM Eastern Standard Time,
> pandanas at oregonfast.net writes:
>
>
>
> If there is any dark area in medical knowledge, that is the CNS,  normal
> or under pathologic situation . Series, statistics, in most  situations
> are
> wide insufficient. The amount of information of the  course of posterior
> circulation, treatments and outcomes is far from  conclusive.
>
> But, I believe, there is other issue in Neuro patients  that with your
> uniform approach to medicine is dangerous (I am not  talking about you as
> a
> physician but as a voice that sculptures minds).
>
> We,Human beings, are what our brain let us be. When we are dealing  with
> such type of patients we are handling the most important future of  their
> outcome. We deal with a patient, not with statistics or averages.  There
> are two types of Evidenced based  Medicine, the one provided  by
> statistics
> and the patient-bedside evidence based.
>
> The  popular evidence based medicine helps to see and organize health
> care,
> investments, policies, resources, and to minimize the chances of
> miss-diagnosis and mistreatment. This can result in good clinical  results
> related to the statistics but not for the single patient we are  treating.
> We can say that it is something we can tolerate. Now, neuro  patients are
> a
> different ball game: it is not the same to send a pt with  30% of  LVEF
> when would have been possible to preserve it at 35%,  than sent a patient
> with 5% less of the left temporal lobe when  would have been possible to
> preserve it.
>
> Evidence based medicine  as we know it does not discriminate the best
> option for patient number  50 than the one for number 100. Are different
> patients, with same  disease but different individual factor affecting
> their individual  course, but by means of statistics they are forced to be
> almost  identical. Situation far from reality. Again this can be tolerated
> in  certain organs and systems, but no in all. The resulting difference in
> neurological patients is talking or not, understanding or not,
> recognizing
> or not, etc with a wide range of outcomes from very mild to  severe, all
> affecting deeply the life of the patient that we are  responsible of.
>
> I hope that whit out underestimating the Evidence  Based Medicine we will
> not abuse of it and try to use it where can be  weak or harmful, as we
> start to develop the concept of  patient/tissue-needs bases medicine.
>
> Remember, at least in medicine,  we are always behind, always, at least, a
> little bit wrong.
>
> My  goal is not to feel secure, but to secure the best outcome for the
> single patient that is expecting the best outcome for his situation.
>
> MY apologies, this is a difficult issue for my English
> JM
>
>
>
>
>
> Let me paraphrase the above eloquent  essay---
> The heck with evidence and science if it does not fit my view of  the
> world,
> and if it prevents me from doing what I want to do regardless,  especially
> if
> it means doing something rather than doing nothing regardless of  risk or
> cost
> (after all the risk and cost is to the patient, not me), and  especially
> if
> it involves hi tech gadgetry and pretty pictures that wil  impress my
> patients
> and colleagues--now, whether it actually  helps the  patient, that is a
> different matter.  I'm all for science and data and  whatnot, but only
> when it suits
> my needs .....
> You asked me for my  evidence, and I provided it--I asked you for yours,
> and....nothing but a long  rationalization as to why it is not necessary
> for you
> to justify your  position, only that I should justify mine--how much more
> obvious can it be  that you refuse to let facts get in the way of what you
> just
> have to believe  anyway., while still paying lip service to the value of
> evidence?
> ERF
>
> rick
>
> i propose we stop translating
>
> sal
> --
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