EBVM - how do you feel about this report?

Re: EBVM - how do you feel about this report?

Arlo Guthrie — Fri, 26 Sep 2014 13:48:40 GMT

[quote user="ruths"]but your last post feels quite rude to me.[/quote]

Yes, JGW, feels a bit like that to me too.

Any chance you could raise your game a little and show a bit of respect for other people's opinions, even if you don't agree with them!

Re: EBVM - how do you feel about this report?

ruths — Thu, 25 Sep 2014 16:01:07 GMT

Oh and I can't even huff without typos - I d rather not be involved etc etc- you get the gist -))

Re: EBVM - how do you feel about this report?

ruths — Thu, 25 Sep 2014 15:59:38 GMT

[quote user="J G Wray"]

[quote user="ruths"] I still can't see that understanding that lots of people are seeing the same things that you are helps how you run your business[/quote]

Hmmm. Your practice doesn't exist in a bubble of personal experience.

[quote user="ruths"]this I'm not sure why you said 'steady' when I said giving medicines that don't work is unethical and poor welfare.[/quote]

Because you are a scintilla away from making a moral judgement. EBVM evangelists are going to get nowhere if they start moralising.

[quote user="ruths"] If we rely on stuff hat doesn't work and ignore stuff that does- then this is poor welfare isn't it? [/quote]

In Latin Grammar this would be classed as a "nonne" rather than a "num" question, commanding the response in the affirmative. Lately this has become know as the "Salmond" question form as in "Wouldn't Scotland be better off independent?" and inevitably the questioner is surprised if they don't get a clear cut "Yes", rather like Mr Salmond. Sooo, in answer to your "nonne" question, "Yes, but..if you project this on to practice from a moralising, evangelising viewpoint, you are gonna get nowhere fast"

[quote user="ruths"] But just now I don't see how it applies [/quote]

Ah me

[quote user="ruths"] And I'm not in a business position at the moment but have had responsibilities over the years and may well do I the future.[/quote]

Ah.

[/quote] What a shame I was hoping we could have a discussion about it and I could find out some more about something that loos interesting and find out how to apply it. Sadly your responses have shown thst you are not interested in a discussion. I realise that the nuances of the Internet are odd so I apologised earlier up thread if I had annoyed you of if I'd overstepped a mark but your last post feels quite rude to me. I shall now bow out with grace before I say anything more. I was not aware that I had to justify my position in life before you would discuss it with me further. If this is the public face of your group, SAVSNET the. I'd rather not be in loved to be honest.

Re: EBVM - how do you feel about this report?

J G Wray — Thu, 25 Sep 2014 13:16:21 GMT

[quote user="ruths"] I still can't see that understanding that lots of people are seeing the same things that you are helps how you run your business[/quote]

Hmmm. Your practice doesn't exist in a bubble of personal experience.

[quote user="ruths"]this I'm not sure why you said 'steady' when I said giving medicines that don't work is unethical and poor welfare.[/quote]

Because you are a scintilla away from making a moral judgement. EBVM evangelists are going to get nowhere if they start moralising.

[quote user="ruths"] If we rely on stuff hat doesn't work and ignore stuff that does- then this is poor welfare isn't it? [/quote]

[quote user="ruths"] But just now I don't see how it applies [/quote]

Ah me

[quote user="ruths"] And I'm not in a business position at the moment but have had responsibilities over the years and may well do I the future.[/quote]

Ah.

Re: EBVM - how do you feel about this report?

ruths — Thu, 25 Sep 2014 09:18:05 GMT

Hi JGW- thanks for your reply- I tried to find out but I could t see where hat information was so I thought I'd ask you -)) I'm sorry if I irritated you re the Rvc/ RCVS - I just wanted to clarify the issue. I still can't see that understanding that lots of people are seeing the same things that you are helps how you run your business. I'm not trying to be adversarial - I'm curious! And I'm glad we agree that we need good evidence on the medicines we give- this I'm not sure why you said 'steady' when I said giving medicines that don't work is unethical and poor welfare. If we rely on stuff hat doesn't work and ignore stuff that does- then this is poor welfare isn't it? Anyway- I do think ebvm is an effective way of answering some of the questions I have about first opinion practice- and I am willing to be convinced that SAVSNET can also help. But just now I don't see how it applies -)) And I'm not in a business position at the moment but have had responsibilities over the years and may well do I the future.

Re: EBVM - how do you feel about this report?

J G Wray — Thu, 25 Sep 2014 09:05:55 GMT

[quote user="ruths"]just a quick note- the vetcompass one is the Rvc not the RCVS[/quote]

Yes. If you read what I wrote, I didn't assign VetCompass to RCVS.

[quote user="ruths"]How does SAVSNET do the data collection and ensure that each vet is talking about the same thing? [/quote]

Go and find out

[quote user="ruths"]And how does it help you to change things if it just a surveillance tool right now?[/quote]

As previously written, we used it on Tuesday in a practice training session discussing what we do and how we deliver it.

[quote user="ruths"] I'm still intrigued about what benefit it is. [/quote]

Do you have management or practice strategy responsibility?

[quote user="ruths"]And my interest here is about medicine and making ethical decisions about treatment[/quote]

The context within which you can work at these, a practice, delivers more than medicine, ethical or otherwise. Do you understand this, in the core of your professional being?

[quote user="ruths"] It's really not great to be prescribing medications and therapies that we have no good evidence that they work. [/quote]

No argument there.

[quote user="ruths"] It's unethical and poor welfare[/quote]

Steady

[quote user="ruths"]. I believe that working well with good ethical decision making is in best business interests and maintains the public trust In the profession.[/quote]

Fine words, fine rhetoric

[quote user="ruths"] I see ebvm as a way of going forwards with this in the future and agree wholeheartedly hat it is in its infancy here[/quote]

Do you see it as the only way forward? Or, do you see your entire professional and personal existence validated through EBVM?

Re: EBVM - how do you feel about this report?

ruths — Thu, 25 Sep 2014 08:16:26 GMT

Project one seems to be about capturing data for vet practices and laboratories ( so a diagnosis does seem to be important) and project two seems to be capturing data but now In real time. Please correct me if I'm wrong. And the aims of the project is to promote preventative health are and advise about zoonoses as far as I can see- but. Neither project one of two seem to be involved in actually doing that. There's no business application that I can see on the aims/ objectives- it's more about preventative health/one health initiatives- but I can't see how it actually delivers those things specifically. It's fascinating !

Re: EBVM - how do you feel about this report?

ruths — Thu, 25 Sep 2014 07:59:08 GMT

Hi JGW- just a quick note- the vetcompass one is the Rvc not the RCVS. How does SAVSNET do the data collection and ensure that each vet is talking about the same thing? And how does it help you to change things if it just a surveillance tool right now? I'm still intrigued about what benefit it is. As far as I can see, they all capture data and then it seems they differ with what their intention is with the data. I csnt work out what SAVSNET's intention is with the data once it feels it has captured enough. And my interest here is about medicine and making ethical decisions about treatment. It's really not great to be prescribing medications and therapies that we have no good evidence that they work. It's unethical and poor welfare. I believe that working well with good ethical decision making is in best business interests and maintains the public trust In the profession. I see ebvm as a way of going forwards with this in the future and agree wholeheartedly hat it is in its infancy here

Re: EBVM - how do you feel about this report?

J G Wray — Thu, 25 Sep 2014 07:42:28 GMT

[quote user="ruths"]What is the difference between savnet, the rvc's vet compass and the Nottingham CEVM? All of them are extracting data from first opinion practices. The Rvc and Nottingham are using to help to advance ebvm.[/quote]

SAVSNET is open,available to the public and practices,is a management tool and is here now. SAVSNET imposes a minimal impact on workflow, Consent is straightforward for instance. It has little impact on establsihed systems and processes. Whilst it is University based it is also a BSAVA initiative. BSAVA has a membership based on practitioners and has a temperamental leaning towards training and education of practitioners and what they do, not what they might do if only they could be motivated to do things differently.

VetCompass and the parochial Nottingham offering are engineering their projects by asking practices to change systems and processes e.g. use VetNom codes for the purpose of gathering evidence on how to make EBVM work, not how to make it work within practice systems and processes.

I get a cold feeling when RCVS get involved in practice clinical systems and processes. They have not gone there before. The PSS is trying through the clinical governance stuff, where Dr Viner figures large incidentally, but their detachment from the reality of everyday mundane practice and dearth of positive incentives makes them singularly unsuitable to be involved. RCVS can only threaten this into us, unless they have some carrots.

EBVM is a Great Ideology. But, it isn;t here now. It's got cumbersome written all over it and it's engineering its processes the wrong way round.

Perhaps another way of looking at this is to ask yourself how successful your practice would be and I mean in a real world commercial sense, rather than a moral high ground sense,if you marketed yourselves as the "EBVM practice"?

JGW

Re: EBVM - how do you feel about this report?

ruths — Wed, 24 Sep 2014 19:12:06 GMT

Sorry- explain not do pain

Re: EBVM - how do you feel about this report?

ruths — Wed, 24 Sep 2014 19:09:28 GMT

Yes, tony, that's my point.. I'm finding it odd to write that -))) But I agree- we need to collect as much data as possible and then make sense of it. JGW- can you do pain how a swot analysis might improve your medical practice? I'm not talking about business- bit your medical treatment. I'm genuinely interested. Thanks

Re: EBVM - how do you feel about this report?

Anthony Todd — Wed, 24 Sep 2014 19:02:14 GMT

[quote user="ruths"]there is a lot of work to be done to make it really useful.[/quote]

Of course there is but that's no reason not to try and, with the coming of computerised records, there is so much data so easily available and, when combined with, say, all the vetsurgers still in practice, so much good sense will come out.

Remember those data cards and the knitting needle you put in the edges to sort males from females etc etc.....

Just how many FLUTDs recur?

What's the real success rate with stifle surgery? [not the published paper with the disaster excluded]

How common are vaccine breakdowns and is it one brand?

How often are PUOs fixed with antibiotics; how often do they turn out to be FIP etc?

And the recent thread on HGE.

Sooner you start the sooner we'll get answers. You all go on about evidence; here's your chance.

Re: EBVM - how do you feel about this report?

ruths — Wed, 24 Sep 2014 18:01:14 GMT

Hi JGW, What is the difference between savnet, the rvc's vet compass and the Nottingham CEVM? All of them are extracting data from first opinion practices. The Rvc and Nottingham are using to help to advance ebvm. I do agree that ebvm is well in the future and there is a lot of work to be done to make it really useful. But I think it's good to aim for something. And I have to say it again- ebvm is about taking your experience as a practitioner and the animal's unique set of circumstances into consideration as well as critical appraisal of what data is available and applicable. It's not just a method of doing whet researchers/ RCVS/ etc tell you to do. It allows for autonomy and nuance.

Re: EBVM - how do you feel about this report?

Evelyn Barbour-Hill — Wed, 24 Sep 2014 12:49:46 GMT

[quote user="J G Wray"] Anyone seen any carrots, 'cos Eeyore is hungry?[/quote]

Sometimes he thought sadly to himself, "Why?" and sometimes he thought, ""Wherefore?" and sometimes he thought, "Inasmuch as which?" – and sometimes he didn't quite know what he was thinking about.

Re: EBVM - how do you feel about this report?

Malcolm Ness — Wed, 24 Sep 2014 07:42:56 GMT

[quote user="J G Wray"]the methodology of evidence gathering for EBVM[/quote]

evidence gathering and EBM are distinct.

It is possible, and in fact it is usually the case that practitioners of EBM neither gather nor analyse evidence for publication and dissemination. It is a clinician-based, patient-centred activity that uses the evidence as it already exists.

Re: EBVM - how do you feel about this report?

J G Wray — Wed, 24 Sep 2014 07:37:11 GMT

[quote user="ruths"] I've looked at the website and it seems that SAVSNET is a surveillance scheme.[/quote]

It is, for now. At the moment it is gathering data, evidence, on what we do, on a grand scale, simply, pragmatically. You could contribute to it, at no cost and with minimal workflow disruption. WHy not sign up today?

EBVM is theoretical, a High Concept and indisputably a Good Idea. However, like particle physics it has begun with a theoretical notion for which it has to devise models which then have to be evidenced in order to be put into practice. It is esoteric in September 2014.

Practitioners , if they are allowed to be involved and round out the Concept, will be asked to change working practices to satisfy the methodology of evidence gathering for EBVM. This is not a pragmatic approach.

We had a team training session last night. We used the SAVSNET pie chart and our own data from our PMS to discuss some concerns that were thrown up by our annual SWOT survey, notably to do with ncreased competition. SAVSNET is making an immediate contribution to our practice and how we will do things. We look beyond the narrowness of the way to fix animals according to EBVM, to the totality of what happens in consultations. We are pretty clear that if we are here and deliver all that is neede from a consultation then we will carry on.

EBVM ain't here now and from the way it is being run it ain't going to be here for a long, long time if it starts from the point of view of the Primary ideology that we should have, as practitioners, delivering veterinary services.

SAVSNET also avoids interaction with the stick-wielder RCVS

JGW

PS Anyone seen any carrots, 'cos Eeyore is hungry?

Re: EBVM - how do you feel about this report?

ruths — Tue, 23 Sep 2014 20:33:55 GMT

[quote user="J G Wray"]

[quote user="Michael Woodhouse"]I may have missed the point[/quote]

.........

[quote user="Michael Woodhouse"]but it appears to me that RCVS is looking for common conditions seen in practice to allow the effort to be concentrated where there is the biggest gain.[/quote]

They need look no further than SAVSNET, the pie chart on the home page, it's there, now.

[quote user="Michael Woodhouse"]It's actually the boring things that often seem glossed over in favour of more interesting (dare I say sexy) diseases.[/quote]

Couldn't agree more that the mundane is what we practice and mundane clinical care is delivered by the legions of practitioners (three legions of ~6,000 full strength) and crucially is what the public know, most of the time. However, what recognition of this is there, what manifestation of acknolwedgement is there at RCVS? Taking this document there is an articulation of bafflement and weird conclusions. Why is that when there are, apparently, vets in their building?

[quote user="Michael Woodhouse"]Pretty similar to what the scheme JGW has signed up to......[/quote]

SAVSNET is here, now and active. It has signed up the PMS providers to allowing SAVSNET to "interfere" in real time with the most mundane of veterinary activities, the consultation in a way that imposes little problem in terms of workflow. That in itself is amazing. It's more pragmatic than the high-fallutin' EBVM concept

I like it on a personal level because it is an extension of a concept devised back in the 90s by Mike Howe with his NADIS, where practitioners armed with tape recorders went on farm visits and recorded their findings according to a grid rather like SAVSNET, sent the tapes into Mikes team who entered the data on a database for publication in UKVet. He got f**k all recognition for this and I address that scandalous state of affairs here and now.

JGW

[/quote] I've looked at the website and it seems that SAVSNET is a surveillance scheme. I agree that it looks great and it's got some really useful data. But I'm not sure that it is an alternative approach to ebvm as as far as I can see it is just collecting information on reasons that animals are seen by the vet. Have I missed something here? I like the graphs and think there is some really great Info there but it doesn't tell me stuff like the best best do( and will in the future) Genuinely, I may be missing a trick but I think from what I've seen it's just not comparable.

Re: EBVM - how do you feel about this report?

Anthony Todd — Tue, 23 Sep 2014 09:54:54 GMT

[quote user="ruths"]the clinet's expected white liquid for diarrhoea[/quote]

That's the art of medical practice!

As Tandy and Hughes said "say something, do something, give something" but I'd modify that by adding "always" before all three.

The other thing that is always missed is the by-the-way, ancillary advice which is the actual cure, such as diet advice for D+ [stop milk!] or flea treatment for atopy etc. etc. both of which are the cure, not the fancy long-named very expensive other things.

Re: EBVM - how do you feel about this report?

J G Wray — Tue, 23 Sep 2014 07:33:48 GMT

[quote user="Michael Woodhouse"]I may have missed the point[/quote]

.........

[quote user="Michael Woodhouse"]but it appears to me that RCVS is looking for common conditions seen in practice to allow the effort to be concentrated where there is the biggest gain.[/quote]

They need look no further than SAVSNET, the pie chart on the home page, it's there, now.

[quote user="Michael Woodhouse"]It's actually the boring things that often seem glossed over in favour of more interesting (dare I say sexy) diseases.[/quote]

[quote user="Michael Woodhouse"]Pretty similar to what the scheme JGW has signed up to......[/quote]

JGW

Re: EBVM - how do you feel about this report?

ruths — Tue, 23 Sep 2014 00:07:34 GMT

Mariette- with the diarrhoea example I was working on the assumption that most of them get better with dietary management and time whatever thier cause. My colleagues would say the sucralfate fixed them and carry in with it because experience told them it worked. I knew my wormer was t fixing the diarrhoea in most cases, but the whole culture of the place was such hat the clinet's expected white liquid for diarrhoea. At least my cases were well wormed by the end of it -)) I'm not sure what else you are trying to say.

Re: EBVM - how do you feel about this report?

mariette asselbergs — Mon, 22 Sep 2014 23:20:55 GMT

Michael, what I mean is that medical best evidence (the Cochrane studies) are based on hundreds of thousands of cases.

In vet studies they are happy to have a few hundred, because the money just isn't there to do mega studies. So the statistical strength of the "evidence" produced is not comparable to what is used in medical evidence based studies.

If you then take into account the diversity of our patient population, caused by genetically narrowed breeds with their particular problems and susceptibility, then it is clear to me that numbers really matter.

By all means do the studies, but I think we should be modest and skeptical to see the results as so much better than the experience of a skilled vet who has kept reading and critically looking at his/her results,

Mariette

Re: EBVM - how do you feel about this report?

Michael Woodhouse — Mon, 22 Sep 2014 22:09:47 GMT

[quote user="mariette asselbergs"]Not either or, I would say, but both. And modesty about Veterinary Best Evidence which cannot nearly compare to Medical Best Evidence.[/quote]

The human medics aren't that far in front

http://clinicalevidence.bmj.com/x/set/static/cms/efficacy-categorisations.html

The part I don't understand is why so many vets seem so dead against EB(V)M. I'm not even sure we need veterinary in there.

EBVM doesn't necessarily need a final diagnosis to work. If the evidence suggests that an intervention is of no benefit to the patient (or maybe even harmful) then we shouldn't be doing it. A lot of our beliefs are clouded by our patient's innate ability to make them selves better and regression to the mean. If we have better evidence then we can make better informed decisions and potentially make more animals better and even lower cost. EBVM might tell us what tests are the most appropriate to run in a given presentation. It might equally tell us when the particular test really is NOT indicated.

I may have missed the point, but it appears to me that RCVS is looking for common conditions seen in practice to allow the effort to be concentrated where there is the biggest gain. It's actually the boring things that often seem glossed over in favour of more interesting (dare I say sexy) diseases. Pretty similar to what the scheme JGW has signed up to......

Re: EBVM - how do you feel about this report?

J G Wray — Mon, 22 Sep 2014 22:07:46 GMT

[quote user="Bradley Viner"]I have a big bag of carrots here at the College for you JGW. You must come in and chew through them sometime.[/quote]

Hee-haw, hee-haw, donkey I may be but don't offer them to me tell everyone! It's the second offer I've had this week from RCVS to come up and see them sometime. Can I bring my dog?

[quote user="Bradley Viner"]It may sound a bit evangelical, but those of us actively involved in the RCVS are keen for it to be seen as a force for good.[/quote]

I just thought it needed repeating

[quote user="Bradley Viner"]We try to reserve the stick for the most intransigent[/quote]

I wish you'd written "We reserve the stick for the most intransigent"

[quote user="Bradley Viner"]I think the comment about diagnoses refers to the value to recording a diagnosis, ideally in some sort of retrievably encoded form, so that the practice data can be usefully analysed.[/quote]

Good man, back on topic. I wasn't clear that there's a depth of understanding about our "motivation" in the document and given the provenance of the project and the only RCVS motivator I know of being the "stick" I wasn't sure there was 'owt else.

What are the carrots?

JGW

Re: EBVM - how do you feel about this report?

mariette asselbergs — Mon, 22 Sep 2014 20:20:07 GMT

"But I would say that one person's experience really can't be better than try to find good evidence."

Not either or, I would say, but both. And modesty about Veterinary Best Evidence which cannot nearly compare to Medical Best Evidence.

Take your example of "diarrhoea" treated with sucralfate or fenbendazole. In our set of patients, how many different presentations of diarrhoea are there? In a German Shephard, a Westy, a polyphagus lab, or an obese dwarf Schnautzer, puppies or aged dogs, wormed or not, farm dog or city dog, fed on royal canis or waggs, table left overs or RMB? Looking for best evidence about treatment of uncomplicated diarrhoea, how do you force these in one diagnostic category? By all means let scientists work on best evidence per particular sort of case, but you need the vet's skill based on experience to place the case in its context and then decide how to deal with the problem.

I think it is the one false comparison Evidence based scientists make: the indicvidual doctor/vet who supposedly cannot compare with the data from hundreds of thousands of cases. But that is the wrong comparison, because the individual doctor or vet deals with the whole patient and the case in contest, whereas the megadata are based on a very limited and strictly defined "case". Both are valuable, each have their limitations.

Not either or, but both.

Mariette

Re: EBVM - how do you feel about this report?

Anthony Todd — Mon, 22 Sep 2014 19:34:57 GMT

[quote user="mariette asselbergs"]So it is not so much leaning on lazy and rusted "what you always do", but a skilled triage of your patients based on experience, then treating the common ones with what has worked for you.[/quote]

More sense from the bare footed one, and more power to you. I say.