From ajha@u.washington.edu Sat Apr 24 10:01:01 1999 Received: from jason01.u.washington.edu (root@jason01.u.washington.edu [140.142.70.24]) by lists.u.washington.edu (8.9.3+UW99.02/8.9.3+UW99.01) with ESMTP id KAA21686 for ; Sat, 24 Apr 1999 10:00:59 -0700 Received: from homer16.u.washington.edu (ajha@homer16.u.washington.edu [140.142.70.17]) by jason01.u.washington.edu (8.9.3+UW99.02/8.9.3+UW99.01) with ESMTP id KAA14460 for ; Sat, 24 Apr 1999 10:00:59 -0700 Received: from localhost (ajha@localhost) by homer16.u.washington.edu (8.9.3+UW99.02/8.9.3+UW99.01) with ESMTP id KAA13108 for ; Sat, 24 Apr 1999 10:00:58 -0700 Date: Sat, 24 Apr 1999 10:00:58 -0700 (PDT) From: Amitabh Jha To: Information for Physiatrists Subject: Re: Let's learn something positive from this discussion In-Reply-To: Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Drs. Goldberg, Dreyfuss, Furman, Lew, and others, I agree that this has been a fascinating, and unfortunately unintended, emotional thread. One (among many) of the lessons I've learned, is one I thought I understood quite well: not having pitch and tone and other characteristics of voice, makes it difficult to understand the context and meaning of words, particularly in isolation, when one cannot interrupt a misunderstanding, before making it grow to greater and greater proportions. I hope it is now clear that my intent was to share my newly acquired knowledge with others, and to help in the conducting of research to further our knowledge, that would be used to treat our patients. As those who know me personally realize, I am in real life a very easy going, friendly person, and the last one to try and start heated discussions (probably to a fault). I greatly appreciate the comments of Dr. Goldberg, and would like to share with others my motivations for choosing a career in academic medicine (which I hope I haven't shattered with my recent screw up), and correct another potential misunderstanding. First let me correct the misunderstanding, Dr. Goldberg suggests that perhaps my advisor is not supportive of my interests and goals. This is far from the truth, and while he is a demanding and meticulous researcher, that is the type of training I wanted from my fellowship. While he may have a reputation beyond my awareness, he has been nothing but supportive with his expertise, time, staff, office space, etc. He has devoted a large portion of his life to studying health care policy and health status/disability/quality of life (talk about difficult literature without much evidence), and I believe matches perfectly with my interest in primary care for individuals with disabilities in this evolving managed care environment. As far as the problems and strengths of Evidence Based Medicine are concerned, I hope I have made clear some of the potential problems. As I mentioned before, we sit in my classes bashing very high quality research, involving millions of dollars, that has been performed by nobel prize winning scientists, in this relatively young science called medicine. And I believe this is good, because it is how any science progresses. However, it causes problems for the actual practitioner (and the lay public), when they are bombarded with new, often contradictory, evidence based on RCTs. As i have mentioned, but probably not made clear, the theory behind RCTs is epidemiology, which is debated among "scientists" as to whether it is a science (after all how can you say smoking "causes" health problems, when you have people like our own Dr. Walter Stolov who smokes, yet defies the odds and remains healthy). Yet I believe epidemiology does have something to offer medical science. There are other theoretical foundations, and other research paradigms, mostly from the social sciences, that may be applied to medical science. I know Dr. James Little and others here at the Seattle VA believe strongly in single subject study designs, which I have not yet had an opportunity to learn in detail. There is also qualitative research which I'm hoping to incorporate into my first project (along with quantitative work because I'm a math junkie). The crux of the problem is how does one determine health care policy on an evolving "medical science" in its infancy? The answer is that policy is rarely, if ever based on science, but instead is based on politics. But my intent in entering academics was to try and perform some of the scientific research that others (certainly not myself) could use to make better policy decisions. As I am quickly learning, my ideal world of seperating myself from the politics, and performing "pure" science is impossible (this is true in any area of research from medicine, to physics, to political science). I thus have much more to learn, and look forward to the continued scientific and political discussions on this list. -Amit Jha On Sat, 24 Apr 1999, Gary Goldberg MD wrote: > This has become a fascinating and somewhat emotional thread. It is clear > that it is hard to be objective about anything when we feel ourselves > personally threatened in a discussion about scientific evidence, and the > original intent of the discussion soon is obscured. > I am fascinated by this discussion because I recently attended (at least > for the first day or so!), the educational session at the AAP meeting in > Orlando on "Evidence-Based Medicine" and realized the great broad gap that > exists in our field between the quality of evidence that is being sought > under the banner of EBM and the quality of evidence that we generally have > available to us in making our clinical decisions. One has to realize that > to do large randomized controlled clinical trials is incredibly expensive > and difficult and demands resources that are generally beyond most people > in this field. I don't want to sound nihilistic about this because there > are things happening within the field, primarily through the efforts of > Steve Tuel and others at the NCMRR at NIH to bring resources into the field > to allow some large-scale trials to be done on specific clinical topics. > This is going to be a very slow and gradual process, speaking from personal > experience having participated in at least two large multicenter drug > trials that involved outcome assessment over an extended period of time. > So, while we teach the idea that large-scale RCTs are an important source > of evidence, we also have to realize the massive effort and cooperative > participation, not to mention the funding, that is involved in carrying > them out. However, I think this is an important realization for the field. > That we will all have to work together and make significant personal > sacrifices to be able to obtain convincing data that will help us make > better decisions for our patients--now and into the future. This is > clearly where the idea of us all being one large family (thank you, Dr. > Lew!) comes in. So, it does not make sense to undermine this standard for > research, but, at the same time, we must realize what is involved in the > commitment to it. It is very easy for a young person coming into the field > who is taught that this is the ONLY standard for data, to become > disillusioned about research in this field because so little of this level > of data currently exists. That is why I think that we must be very careful > about how we use EBM for teaching in journal clubs etc. We CANNOT respond > to our current situation by simply saying that we don't have the resources > to do large-scale RCTs so let's forget about doing research of any > kind--that is not helpful at all. We CANNOT go around tearing to shreds > and dumping any type of research done by our own colleagues that does not > meet the EBM standard. There are wide and wonderful areas of research of > direct interest to the field that can be done without having to go all the > way to the seemingly untouchable 'EBM-approved' standard. > SO, what can we do in the meantime? Well, we can do precisely the kind of > work that Dr. Dreyfuss has done, and here I am thinking especially of the > paper he did with Dr. Dumitru on dermatomal SEP in lumbosacral > radiculopathy (Muscle & Nerve. 19(4):442-9, 1996 Apr). This is a paper > that I have found to be precisely the type of research that can > significantly advance our practice WITHOUT having to be a large-scale RCT. > It has personally heavily influenced my clinical electrodiagnostic practice > and it is a paper that Keith Chiappa, the Harvard-based guru of evoked > potentials, recognizes in his textbook as the bottom line on dermatomal SEP > use in diagnosing LS radiculopathy. Everyone on this list who has not seen > the paper should look it up and read it carefully as an example of what > anyone with a decent clinical practice can do to contribute to the > literature, without having a massive NIH grant, in a meaningful way. All > you need to do is to maintain a research-oriented attitude that permeates > your practice and be willing to make the necessary sacrifices to learn the > needed skills (as Dr. Dreyfuss clearly has done, clearly with mentorship > from Dr. Dumitru) in order to do this type of work. What kind of skills? > Well, we can get into that some other time. It begins by reading the > literature and being intimately familiar with what distinguishes good > research from marginal research. But then you have to take the next step > to gear up to do some decent research yourself. You have to get beyond the > attitude that one can potentially fall into from the way some EBM-inspired > journal clubs operate--that nothing is good enough--and not take the next > step. You need to take the next step, learn the skills and do the work. > So, Amit, my enjoinder to you is to take what you have learned through > critical review of the literature and turn it into something positive for > the field. Take the next step, find a compatible mentor, learn the skills > and do the work. I look forward to learning from it and having it > significantly influence my clinical practice. > I encourage everyone on this list to take home something positive from this > exchange between Paul, Amit, Mike and others and commit yourselves to the > advancement of the field in one way or another through the performance of > defensible research, whether it involves working together in large > cooperative multicenter groups to get the kind of 'EBM-approved' evidence > that we need badly in the field (when or if such an opportunity may come > along), or plugging away in small but intense groups in our own practices > doing the best we can with the resources we have available to us (the most > precious of which, of course, is our patients and their trust) to make our > contributions to the field. > --GG > > > > >Drs. Furman, Dreyfuss, and others who treat low back pain, > > This e-mail format I think is distorting the intent of my > >comments. I am very sorry for any misunderstanding that may have > >occured, and would be greatful if you would let me explain my situation, > >and then give forgiveness. > > First, I know very little of the literature on low back pain, but > >honestly believe there may be a role for injections in it's treatment - in > >fact I have often referred my patients (during residency) to injection > >specialists for cases that were beyond my ability. > > Second, I am a little jealous of my fellow residents who are > >making much more money than I am currently, and probably ever will. But I > >believe practitioners should make more money than researchers - after all > >a researchers entire's life work may lead to nothing - while a > >practitioner has at least helped some patients. > > Third, given the current state of health care, and my belief in > >injections, my intent was to help our specialty (which I greatly respect - > >it treats patients other specialties may regard as hopeless) advance the > >scientific evidence for our treatments. When Dr. Dreyfuss asked for > >assistance with his RCT, I thought I'ld give what advice I could, but > >being a novice researcher, thought of getting the help of Rick Deyo (who > >knows back pain research very well). However, to try and be politically > >correct (which I'm also learning to do) I thought it best to go through my > >advisor (who donates his time to further my training). When I mentioned > >this RCT, he felt that it was a distraction to my research interests and > >training - but wanted to know more about the person making the request, > >and "where he's from." Not being familiar with the spine literature, and > >wanting information on Dr. Dreyfuss's location, I resorted to the web (I > >didn't think MEDLINE would give me this info). I came upon the ISIS site > >and looked up Dr. Dreyfuss, and out of curiosity looked at some of the > >other info on the site. > > My 1st error was in trying to hold the info on a web site > >(consumer oriented) up to the same standards as "scientifc" research. My > >second error was in hastily sending en e-mail last night to my advisor, > >who tends to want info right away, and using inappropriate language to > >describe what I had mistakenly held to scientific standards from a > >consumer web page. My third error, was in using the term "desperate", > >which may be a sign of the environment I'm in - where all we discuss is > >the coming doomsday for all medical treatments, and then projecting that > >on to Dr. Dreyfuss. My 4th was obvious in sending the e-mail as a reply > >instead of forward. > > I have tried to make amends but not very succesfully, and I think > >the reason continues to be to try and get people in our specialty > >interested in research. I really do appreciate the efforts Dr. Dreyfuss > >has made to perform quality research while keeping a practice. Back pain > >is very difficult to study, and requires careful analysis of every step > >from anatomy to intervention to outcome - and I appreciate his efforts in > >all of these areas. (It's probably more than I'll ever accomplish, as I'm > >spinning my wheels thinking, instead of acting and discovering anything). > > Nonetheless, as Dr. Dreyfuss, and many others on this list have > >pointed out. We do need more quality research, and since my interest > >isn't in low back pain, I wanted to encourage others to pursue at least > >some research in this area, because if we don't have people to make > >scientific arguments for treatments we all believe are good for our > >patient's, other people will use evidence against us. > > Once again, I truly hope everyone accepts my apologies. I feel > >horrible for this terrible misunderstanding, and hope that I haven't > >estranged myself from the entire physiatric community. > > > >-Amit Jha > > > > > >On Fri, 23 Apr 1999 Mbf@aol.com wrote: > > > >> Amit, > >> > >> Unfortunately, your initial post speaks much louder than your attempted > >> retraction. Dr Dreyfus is one of the truest researchers in ANY > >>specialty. > >> He attempts pure research and tries to maintain a clinical practice while > >> doing so. If you had done YOUR research (like Medline perhaps) you > >>wouldn't > >> have jumped to the conclusion that he's part of a group doing "crappy > >> research". He designed a true RCT. His only design flaw was looking over > >> the simple fact that people who hurt want the real medicine and don't > >>want to > >> risk being in the control group. > >> > >> The fact that you described Dr Dreyfus as "desperate" for wanting advise > >> from one of you is disheartening. It makes folks like me who contemplate > >> much less rigorous projects realize that we will never live up to your > >> standards. > >> > >> Perhaps your "errant" post will be an overall postive. Hopefully it has > >> opened your eyes a bit wider. > >> > >> Michael B. Furman, M.D. > >> Medical Director > >> The Center for Spine and Sports Rehabilitation > >> 2901 Pleasant Valley Rd > >> York, PA 17402 > >> W(717)848-4800 > >> H(717) 252-9616 > >> fax (717) 755-1695 > >> email: mbf@aol.com > >> > >> ________________________________________ > >> The Post: > >> > >> > >> Donald- FYI > >> 1) No wonder their research is so poor. > >> > >> 2) All I could find on the web was that he's from Tyler, TX, and > >> belongs to the International Spinal Injection Society > >> > >> http://www.spinalinjection.com/ > >> > >> Full of crappy "research" > >> > >> 2) He sounds desperate; in case you see "Rick" and want to > >> discuss it with him. Otherwise I'll at least inform Dr. Deyo of this guys > >> interest next time I see him. > >> > >> -Amit > >> > >> ______________________ > >> The retraction: > >> > >> > >> > >> > >> Paul has informed me that my recent accidental post to this list may have > >> sounded harsh and on re-reading the message I must admit it sounds > >> rather ivory towerish. Given the nature of e-mail communication, and > >> potential for misunderstanding out of context, I would like to apologize > >> to any who took offense. > >> > >> As we all know studying back pain is a very difficult endeavor, but one > >> that requires our attention given the current state of health care > >> financing. The recent research developments in the treatments for breast > >> cancer (traditional chemotherapy vs bone marrow transplant) offer a great > >> example of the dilemma: > >> > >> 1) will insurance companies continue to pay for a very expensive > >> treatment that has not proven to be efficacious at a population level. > >> > >> 2) how do you apply the findings from these studies to any > >> particular patient with end-stage breast ca > >> > >> 3) if such treatment isn't funded, how will we make any progress > >> towards treating the condition. > >> > >> The problem is even more evident when one looks at a condition like low > >> back pain with such high prevalence and morbidity. > >> > >> Sitting in this ivory tower, I don't have any answers; and appreciate the > >> efforts Dr. Dreyfuss, and others at ISIS, are making to futher the > >> understanding of the causes and treatments of low back pain. I do think > >> that more young physiatrists should consider combining some research > >> training into their clinical fellowships, so that we as a specialty can be > >> the leaders in developing proven therapies. > >> > >> -Amit Jha > >> >> > >> > >> > >> > > .