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Re: ob profession (was postpartum intercourse)From: Robert J. Woolley (wooll005@gold.tc.umn.edu)Sun Jun 29 23:52:19 1997
In message <33B87A7E.4B62@accessnv.com> writes: > I fear your evidence will be a recitation of RCTs. And so we shall on > bended knee fall under the spell of the RCT. But let us go back one > step. I agreed that there may be (emphasis) may be more harm than good > from a medical procedure. What is harm and what is good? These remain > undefined. It was your statement, not mine. I am saying that an RCT is > not above critique. But my feeling from your posts on this list is that > the Ace you always play is the RCT. Once you play your Ace, the > discussion is over. Well, I don't think so. I must know the study design > etc before I accept whatever harm you allege from whatever benefit I > state. I'm not getting into that with you. The original allegation was > that obstetricians are incompetent fops because they (at least 51% > according to your citation) are doing episiotomies. What proof do you > have of that. Where is your RCT that defines incompetency and how doing > an episiotomy supports that allegation? Not forthcoming; instead you > wish to get into a discussion of the pros and cons of episiotmy which is > not the essence of my discussion. I'll freely admit that in discussing any piece of scientific research there is an irreducible element of subjectivity: e.g., were the trial's subjects *sufficiently* like other patients to allow generalizability; were the possible sources of bias *adequately* addressed and reduced; are alternative explanations for any effect found *convincingly* rejected, etc. It is on precisely such grounds that the tobacco companies, e.g., maintain that all the research showing a causal effect of cigarettes on heart or lung disease are inadequate to the task. But you are now doubly trying to shift the burden of proof imporperly. Firs, if you are advocating a procedure for a patient, you have the burden of proof to show that it is in her interest. (Since this is nearly impossible for any one patients, except on probabilistic grounds, we rely on studies doen on other patients which we think are generalizable to the one at hand.) But secondly, if there is an RCT, and especially when there are several of differening designs reaching the same conclusion, it seems to me that the burden of proof is on you to show why you find them inadequate as a guide to practice. This can be done; one of the 5 trials is, frankly, a disaster, and should never have seen the light of day, even though it is technically an RCT. You would have no difficulty showing it to be an unreliable guide (even though ti reaches the same conclusion as the others). But the others are, IMHO, methodlogically rigorous, particularly the Argentine and Montreal trials. Your choices, then, are to reject them out of hand because you don't like their conclusions (or because nobody has spoon-fed them to you in a convincing way), or study them and decide whether they are sound tests of the research questions they addressed. If you conclude that they are not, I would be most interested in your reasoning. Have you actually done this? If not, then I think I am quite justified in concluding that your continuing to perform episiotomies is a demonstration of professional ignorance or obstinacy, either one of which is a pretty good indicator of "incompetence", as you phrase it. ---------------------------------------------------------------------------
--------------------------------------------------------------------------- Bob Woolley -- --------------------------------------------------------------------------- St. Paul, Minnesota
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