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 De Nacht van Descartes, georganiseerd door het Descartes Centre en Studium GeneraleDatum: donderdag 24 september 2009 Locatie: Geertekerk, Geertekerkhof 23 Utrecht Toegang: Gratis; u dient zich wel te registreren voor de lunch via infodescartescentre@uu.nl Bewezen beter. Over evidence based medicine tussen vakmanschap en wetenschap René Descartes zag de mens als machine. Dit mechanistisch mensbeeld bleek veel beter in staat om gezondheid en ziekte te verklaren dan de daarvoor gangbare opvatting, die ziekte als een gebrek aan balans tussen de ziekte lichaamssappen beschouwde. Door wetenschappelijke bestudering van individuele organen - in plaats van de hele mens - heeft de geneeskunde vanaf de Verlichting grote vorderingen gemaakt. Het resultaat is onze ongekende staat van gezondheid en welzijn. Toch leidt dit niet zonder meer tot vertrouwen in de wetenschap. Patiënten hebben vaak het gevoel behandeld te worden als een machine, artsen voelen zich beperkt in hun vakmanschap en ook beleidsmakers hebben er last van dat de medische wetenschap versnipperd is in specialismen. Wat is er verloren gegaan en kunnen we aandacht voor de hele mens terugbrengen op een 21ste-eeuwse en wetenschappelijke verantwoorde wijze? Wat kunnen we leren van de geschiedenis en filosofie van de medische wetenschap? amoxil 500mg De Nacht van Descartes wordt jaarlijks georganiseerd door het Descartes Centre for the History and Philosophy of the Sciences and Humanities en Studium Generale en bestaat uit een vaksymposium en een publieksprogramma. Beide onderdelen zijn onafhankelijk van elkaar te volgen en voor iedereen vrij toegankelijk. Lees hier het artikel uit de UMC-krant n.a.v. de Nacht van Descartes Bekijk hier een fotoverslag van de Nacht van Descartes (fotograaf: Wieke Eefting) Dagprogramma 10.00-16.15 (Voertaal: Engels) Deskundigen op het gebied van evidence based medicine Jeremy Howick (Oxford), Ted Porter (UCLA), Rosser Matthews (Maryland), Wiebe Bijker (Universiteit Maastricht) en Stefan Timmermans (UCLA) gaan in debat onder leiding van Frank Huisman (Geneeskunde Utrecht). Zij plaatsen het zoeken naar natuurwetenschappelijk bewijs in de geschiedenis van de geneeskunde en in onze tijd. Behoedt evidence based medicine artsen voor willekeur of staat het de uitoefening van hun vak juist in de weg? Is er nog voldoende ruimte voor vakmanschap en ervaring? En kan de patiënt nog meepraten? 10.00 Welcome with coffee, opening by Arie Nieuwenhuijzen Kruseman (Chair Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst) 10.30 - 11.00 Frank Huisman (Utrecht; chair of the day program): General introduction 11.00 - 11.30 Jeremy Howick (Oxford): What on earth was medicine based on before EVIDENCE-Based Medicine? A philosophical inquiry. (Powerpoint) Abstract: The Evidence-Based Medicine (EBM) movement was announced as a “new paradigm” in 1992. Many reacted to this pronouncement by wondering what on earth was medicine based on before if not evidence. Given that ‘evidence’ simply means “grounds for belief”, it follows that medicine has always been ‘evidence’-based: even quacks can justify their convictions. If EBM is new – and its proponents insist it is – it must be a particular view of what counts as (good) evidence. At its core, EBM favours comparative clinical studies (such as randomized trials) over reasoning from basic science (‘pathophysiologic rationale’) and expert judgment. In this paper, I will critique the EBM system from a philosophical point of view, and attempt to answer whether the EBM view of evidence can be justified. I will argue that contrary to what many have asserted, a strong, non-circular rationale for the EBM ‘system’ can be provided by measuring health outcomes. Video Huisman en Howick 11.30 - 12.00 Discussion 12.00 – 12.45 Lunch (registratie noodzakelijk) 12.45 – 13.15 Ted Porter (UCLA): Evidence, Openness, and Medical Accountability. (Powerpoint) Abstract: Evidence-based medicine aspires to improve medical practice less by informing and persuading doctors than by holding them accountable. Its recent prominence seems overdetermined, since it is supported by the most important elements in the modern reconstruction of medical practice: research science, medical instruments and technologies, corporate capitalism, private and public insurance, and the welfare state. These have conspired to open medicine up for inspection by outsiders, leaving it less and less a private matter for physicians and their patients. In the name of protecting patients and of holding down costs, state and private insurers have imposed a regime of financial and scientific accounts, of controlled trials whose results are judged by levels of statistical significance, allied to budgetary oversight. The ancient power of the profession of medicine involved little capacity to regulate the work of physicians, beyond determining who could be one. This professionalism incorporated a presumption of skill and expertise. EBM rejects skill as tacit and incommunicable, demanding adherence to standards that can be enforced by outsiders. Its mythical power is sustained by its ability to ally metastatistical studies and expert panels with call centers where lowly clerks approve and reject medical procedures. 13.15 – 13.45 J. Rosser Matthews (Maryland): Historicizing Evidence-Based Medicine: The Latest Effort to Introduce "Population Thinking" into the Clinical Encounter. (Powerpoint) Abstract: In a programmatic 1992 statement, the Evidence-Based Medicine working group heralded their approach, based on quantitative population-based reasoning, as "a new paradigm," which "de-emphsizes intuition, unsystematic clinical experience, and patholophysiologic rationale ... and stresses the examination of evidence from clinical research." This language implied that Evidence-Based Medicine was fundamentally "new"; however, the dichotomy between "patholophysiology" and (population-based) "clinical research" can be understood historically as an ongoing tension between contrasting visions of medical science that have vied for epistemological authority since (at least) the mid 19th century. This paper will illustrate this tension by surveying various 19th and 20th century debates among biomedical researchers over the merits of population-based thinking. After highlighting the structural similarity between these historical debates and the contemporary issues surrounding Evidence-Based Medicine, the paper will argue that Evidence-Based Medicine can be understood, from the perspective of the history of medicine, as a contemporary challenge to the biomedical reductionist model of research associated with what has been called the "Golden Age" of 20th century medicine. Video Porter en Matthews 13.45 – 14.15 Discussion 14.15 – 14.45 Tea break 14.45 – 15.15 Wiebe Bijker (Maastricht): The Paradox of Scientific Authority — or: how is certainty of medical science constructed?. (Powerpoint) Abstract: On the basis of an analysis of the work of the Health Council of the Netherlands, Bijker will analyse how scientific authority in medicine is created in an era in which increasingly all kinds of authorities seem to be questioned. He will give examples of Dutch policy making and scientific advisory work in this area, as well as from the practice of using scientific knowledge in medicine. The Health Council’s advisory report Medisch handelen op een tweesprong (Medical practice at a crossroads) published in 1991, was an important step in establishing evidence-based medicine in the Netherlands. 15.15 – 15.45 Stefan Timmermans (UCLA): EBM in Practice: Professions, Patients, and the Pay-Off. (Powerpoint) Abstract: Evidence-Based Medicine can be viewed as a solution for the professional problem of widespread variation in the practice of medicine. Researchers established that health care differs greatly across geographical areas based on physician practice styles. Because one of the key elements of professional work is to provide up-to-date scientific expertise to clients, such practice variation poses a problem for clinicians. Why, for example, would insurers or government authorities pay for hospitalizations if patients with similar conditions are successfully treated during office visits? To offset more draconian regulatory measures or cost-cutting measures, medical professional organizations have engaged in a massive standardization effort under the term evidence-based medicine. Yet, the actual implementation of evidence-based medicine shows that practice variation continues unabated. What, then, are the effects of the widespread diffusion of guidelines, metareviews and other tools for clinical work and patients? Using some selected examples, I will show the conditions under which evidence-based medicine works, in the sense of standardizing clinical behavior and the conditions under which it remains mostly a political move in the ongoing struggle for dominance in the medical field. Video Bijker en Timmermans 15.45 – 16.15 Discussion Avondprogramma 20.30-22.30 (Voertaal: Nederlands) Artsen handelen steeds meer volgens wetenschappelijk bewezen methoden. Toxicoloog Melanie Peters (Studium Generale, UU) zal betogen dat het wetenschappelijk onzuiver is om hieraan de zekerheid te ontlenen die patiënten en beleidsmakers zoeken. Doen medische feiten er dan niet toe? Neuroloog Jan van Gijn (UMC) laat zien hoe de medicus omgaat met wetenschappelijk bewijs. Hoeveel ruimte is er voor de individuele patiënt die daar misschien niet in past en voor – onbewezen – vakmanschap? Jozien Bensing (Nivel en Gezondheidspsychologie, UU) ontving in 2006 de Spinozaprijs voor haar onderzoek naar spreekkamerrituelen. Is het inderdaad zo dat de arts zich niet meer richt op de patiënt als geheel? Mirko Noordegraaf (Bestuurswetenschappen, UU) zal de avond leiden. Voorzitter avondprogramma: Mirko Noordegraaf (Utrecht) 20.30 - 21.00 Melanie Peters (Studium Generale, UU) (Video) 21.00 – 21.30 Jan van Gijn (UMC) (Video) 21.30 – 22.00 Jozien Bensing (NIVEL en Gezondheidspsychologie, UU) (Video) 22.00 – 22.30 Discussie ESSAYWEDSTRIJD Aan de Nacht van Descartes 2009 was een essaywedstrijd gekoppeld, die georganiseerd werd in samenwerking met het Ublad. Zo’n 20 jaar geleden werd de term Evidence-Based Medicine (EBM) geïntroduceerd. Bij het maken van een keus voor de behandeling van een patiënt diende de arts gebruik te maken van wetenschappelijk bewezen inzichten. Waarom was die oproep nodig? Had de geneeskunde zich daarvoor dan niet op de wetenschap gebaseerd? Hoefde de effectiviteit van medische ingrepen voorheen niet te zijn bewezen? Is de geneeskunde sindsdien beter en effectiever geworden? Kan de introductie van EBM misschien ook worden verklaard door factoren van niet-medische aard? Wat heeft EBM bijvoorbeeld te maken met het streven naar kostenbeheersing in de zorg en met de juridisering van het medisch handelen? En heeft EBM bijgedragen aan een versterking van de medische professie of vormt het juist een bedreiging voor haar autonomie? Kortom: hoe moeten we evidence based medicine als fenomeen begrijpen en evalueren? Een jury bestaande uit Frank Huisman (Descartes Centre / UMC Utrecht), Melanie Peters (Studium Generale), Armand Heijnen (Ublad), Jan van Gijn (UMC Utrecht) en Wijnand Mijnhardt (Descartes Centre) beoordeelden de bijdragen. Het bekroonde essay is gepubliceerd in het Ublad van 1 oktober 2009. De auteur kreeg bovendien een prijs bestaande uit boekenbonnen ter waarde van 250 Euro. Winnaar essaywedstrijd: Jacoline Bouvy, PhD-student Farmaceutische Wetenschappen in Utrecht. Lees hier haar winnende essay Ranking evidence is not enough. Doctors have always treated patients according to what they believed were effective treatments. Until the late 19th century, however, bloodletting was thought to be a cure for a variety of diseases. Today, we prefer treatments that are ‘scientifically proven’ to be effective and expect our doctors to practice evidence-based medicine. But evidence-based medicine is not a medical doctrine: it is a set of tools that allows doctors to practice medicine by preferably using treatments that have been shown to be efficacious and effective. It helps doctors to be able to provide the ‘best’ therapies to their patients. However, evidence-based medicine is far from perfect and holds several weaknesses. The foundation of evidence-based medicine is the ‘hierarchy of evidence’ model, which ranks different types of scientific research study designs according to the authority these types of research hold. The hierarchy of evidence model wrongly regards the randomized controlled trial (RCT) (and systematic reviews of RCTs) as the ‘best’ type of medical research. Furthermore, it discriminates against lower ranked study designs that in the past have contributed to a great extent to current knowledge of diseases. In the development of medical evidence-based guidelines, the hierarchy of evidence model is used to rank the authority of different types of research. The randomized controlled trial and systematic reviews of RCTs are ranked above observational studies, case reports and expert opinion. A systematic review of at least two independent randomized double-blinded controlled trials of sufficient quality and size is considered the highest form of evidence in medicine followed by a single randomized double-blinded controlled trial. Ranked below RCTs are comparative studies (e.g. case-control studies and open trials), and at the bottom we find non-comparative observational studies and expert opinion. The randomized controlled trial is the closest medicine has come to a formal experiment which is why it is ranked highest. Yet, it is exactly the nature of RCT design that is problematic for its application in medicine: the highly controlled circumstances and selected patient population result in problems with external validity. The homogenous patient sample of an RCT is not very representative for the real-life, daily practice of health care, where the patient population is naturally very heterogeneous. Possibly even more important, pharmaceutical companies that have an obvious interest in publishing promising results of their products often fund RCTs. This does not mean we cannot trust the outcomes of their studies; it does mean we have to be aware of the issue of objectivity in their studies. Ideally, their results should be repeated by independent studies. Objectivity Unfortunately, neither does independent research guarantee objectivity of study outcomes. The well-known ‘Scientists behaving badly’ publication (2005) has shown that 33 percent of researchers have engaged in at least one form of serious misbehavior in research (Martinson et al. 2005)*. Thus, objectivity in medical research and publications in scientific journals does not exist. The hierarchy of evidence model does suggest that when study design conditions (e.g. sufficient quality and size) are met, RCTs will always produce reliable results. This is a wrong assumption. Randomized controlled trials have another major fallacy: they are short-term oriented. Observational studies (that are ranked below RCTs) are essential in investigating longterm effects of treatments and determinants of disease. The Framingham Heart study that started in 1948 is an example of a well-known observational study that has contributed greatly to our knowledge of cardiovascular diseases. Also, the relationship between smoking and lung cancer was shown not by randomized controlled trials but by epidemiological study designs. These examples clearly show that study design does not necessarily indicate the importance of the study’s results to the field of medicine. Evidence-based medicine and its hierarchy of evidence model clearly put randomized controlled trials above observational studies and, therefore, forces rigid judgment on their value and utility in medicine. But history has shown us that we need to look beyond study design to determine the true quality of scientific research and the extent to which published studies contribute to our knowledge of diseases and treatments. The hierarchy of evidence model is useful but has several limitations that create a need to look beyond evidence-based medicine. True evidence-based medicine should value research according to its importance and contribution to our increasing understanding of medicine. The evidence-based medicine model that simply ranks scientific studies based on their study design is not sufficient. *Martinson BC, Anderson MS, de Vries R. Scientists behaving badly. Nature 2005; 435 (June): 737-738. LEESTIPS Goed kijken mag weer, NRC Handelsblad, 6 juni 2009 (pdf) Interview met Jozien Bensing in Intermediair Communicatie arts heeft meetbaar effect op genezing, Het Financieele Dagblad, 18 februari 2009 T.M. Porter, Trust in numbers. The pursuit of objectivity in science and public life (Princeton University Press, 1995) J. Rosser Matthews, Quantification and the quest for medical certainty (Princeton University Press, 1995) R. Bal, W.E. Bijker, R. Hendriks, Paradox van wetenschappelijk gezag. Over de maatschappelijke invloed van adviezen van de Gezondheidsraad (Den Haag: Gezondheidsraad, 2002) Stefan Timmermans and Marc Berg, The Gold Standard: The Challenge of Evidence- Based Medicine and Standardization in Health Care (Temple University Press: Philadelphia, 2003) |
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