Progress in evidence-based medicine: JAMA articles

The  October 15 issue of JAMA contains a commentary on the article on EBM published in 1992. Both are available free online.

Montori VM, Guyatt GH. Progress in evidence-based medicine. JAMA. 2008 Oct 15;300(15):1814-6.

In 1992 JAMA published an article by the Evidence-Based Medicine Working Group focusing on the role of evidence-based medicine (EBM) in medical education.1 Although the term evidence-based medicine first appeared in the published literature the prior year,2 the JAMA publication brought both the label and the underlying philosophy to the attention of a wider medical community.

The article was audacious in suggesting that EBM represented a new paradigm in the teaching and practice of medicine by deemphasizing unsystematic clinical observations, pathophysiological inference, and authority. The article honored traditional skills (eg, understanding biology, demonstrating empathy), but emphasized new skills that learners must acquire and use: question formulation, search and retrieval of the best available evidence, and critical appraisal of the study methods to ascertain the validity of results. The article aggressively presented EBM as a fundamentally new approach.

The original article:

Evidence-Based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992;268(17):2420-2425.


Ethical issues arising from commercial sponsorship and from relationships with the pharmaceutical industry

  Just published in Cephalalgia [subscription required]:

Steiner TJ. Ethical issues arising from commercial sponsorship and from relationships with the pharmaceutical industry–Report and Recommendations of the Ethics Subcommittee of the International Headache Society. Cephalalgia. 2008 Sep;28 Suppl 3:1-25.
Preface: These recommendations, the second set developed for the International Headache Society (IHS) by its Ethics Subcommittee, evolved over 3 years. This extended period allowed time for public consultation, an important part of the formulation process, and for consequent revision. The recommendations were presented in this final form to IHS Council in late 2005, and approved for publication in Cephalalgia. The delay from then until now would have been better avoided. The reasons for it, which did not lie with the Subcommittee, are not of current interest. What matters is that these recommendations remain entirely relevant to their purpose. In one area – the registration of clinical trials – matters have moved on in the interim. As the Subcommittee anticipated, registration of trials is becoming standard practice. This goal is not yet achieved, but laudable and largely voluntary initiatives by the pharmaceutical industry have brought about much recent progress. Clear international consensus has yet to emerge on what needs to be included in a clinical trials registry, and when. This does not help, since it is not entirely certain what the desired end is. But it seems likely that, with or without further regulation, this end will be both clear and in sight in not too long. Headache will benefit, along with all other fields of medicine.
Summary of recommendations
1.1 Conflicts of interests in relationships with commercial sponsors
1.2 Commercially sponsored research
1.3 Commercially sponsored clinical services
1.4 Commercially sponsored education
1.5 Marketing


  About year ago I wrote a post entitled Micronations, which included a description of Sealand. Because that post has received a large number of hits, I thought you all might be interested in hearing about the The Seasteading Institute:

Seasteading means to create permanent dwellings on the ocean – homesteading the high seas. A seastead, like in the picture above, is a structure meant for permanent occupation on the ocean.
Why would you want to do that?  Because the world needs a new frontier, a place where those who are dissatisfied with our current civilization can go to build a different (and hopefully better) one.

The Institute was founded by Wayne Gramlich and Patri Friedman. They hope to have a prototype sailing off the coast of San Francisco by 2009.

Read the Institute’s press releases; watch a PowerPoint show by Patri Friedman. And view an artist’s conception of what a large seastead based on the spur design could look like. The Seasteading Institute envisions vast clumps of these structures forming city-states in the open ocean. (Illustration: Valdemar Duran)

Here is an article from Wired: Peter Thiel Makes Down Payment on Libertarian Ocean Colonies (05/19/08)
With a $500,000 donation from PayPal founder Peter Thiel, a Google engineer and a former Sun Microsystems programmer have launched The Seasteading Institute, an organization dedicated to creating experimental ocean communities “with diverse social, political, and legal systems.” “Decades from now, those looking back at the start of the century will understand that Seasteading was an obvious step towards encouraging the development of more efficient, practical public-sector models around the world,” Thiel said in a statement.

Here is a description of the Principality of Sealand, another “new frontier”: 
The history of Sealand is a story of a struggle for liberty. Sealand was founded on the principle that any group of people dissatisfied with the oppressive laws and restrictions of existing nation states may declare independence in any place not claimed to be under the jurisdiction of another sovereign entity. The location chosen was Roughs Tower, an island fortress created in World War II by Britain and subsequently abandoned to the jurisdiction of the High Seas. The independence of Sealand was upheld in a 1968 British court decision where the judge held that Roughs Tower stood in international waters and did not fall under the legal jurisdiction of the United Kingdom. This gave birth to Sealand’s national motto of E Mare Libertas, or “From the Sea, Freedom”.

Postgraduate Medical Education

  From the August 2008 issue of Postgraduate Medical Journal:

Leach DC.  Changing education to improve patient care. Postgrad Med J 2008 Aug;84(994):437-41.

Abstract: Health professionals need competencies in improvement skills if they are to contribute usefully to improving patient care. Medical education programmes in the USA have not systematically taught improvement skills to residents (registrars in the UK). The Accreditation Council for Graduate Medical Education (ACGME) has recently developed and begun to deploy a competency based model for accreditation that may encourage the development of improvement skills by the 100 000 residents in accredited programmes. Six competencies have been identified for all physicians, independent of specialty, and measurement tools for these competencies have been described. This model may be applicable to other healthcare professions. This paper explores patterns that inhibit efforts to change practice and proposes an educational model to provide changes in management skills based on trainees’ analysis of their own work.

This is a reprint of an article by then ACGME executive director Dr. David C. Leach, published in 2001 in Quality in Health Care, and it is available free online:
Leach DC.  Changing education to improve patient care. Qual Health Care. 2001 Dec;10 Suppl 2:ii54-8.This was a special supplement entitled: Leadership and Learning, and it is available free online.

Here is another article from a recent issue of Postgraduate Medical Journal, also available online:
Swanwick T. See one, do one, then what? Faculty development in postgraduate medical education. Postgrad Med J 2008 Jul;84(993):339-43.
Interest in the development of medical educators working in the postgraduate sector is running high. Driven by three interlinked trends–the professionalization of medical education, increasing accountability, and the pursuit of educational excellence–there is a growing need for high quality and sustained faculty development programmes across the network of education providers. Postgraduate medical education has a number of unique features that set it apart from undergraduate medicine, to which faculty development programmes need to cater. The key issue for the future will be how to engage the service in the business of education. Widespread cultural change is required and this will require effective and sympathetic leadership from postgraduate training institutions, hospitals and health authorities.