Evidence Based Medicine: An Overview

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????????? ???? ???? ???? (1956)

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Higher order thinking
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  ????? ?? ?? ???? ?? ???? ???? ? ????? ???? ??????
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• Judgment based on standards to accept, reject, or
  suspend judgment about a claim and the degree
  of confidence with which we accept or reject it.

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• ???? ???? ????? ?? ???? ?????????????
• Physicians and judges need and use CT skills more
  than every other disciplines

15
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16
Religious view

• Give good news to my servants, those who listen
  to the word then follow the best of it Those are
  they whom Allah has guided and those it is who
  are the men of understanding. 
• QUR'AN (THE CHAMBERS - ZOMAR, 17-18)
• " ????? ?? ?? ?????? ?? ?? ?? ??? ??? ??? ?? ????
  ? ?????? ?? ?? ??? ?? ????. ????? ?? ????? ?????
  ????? ??? ? ??? ?????. "

17
??????? ???? ????

• Socrates
• Plato
• Francis Bacon
• ,.
• Replaced formal logic in universities from 1941

18
Indications for language

• Descriptive
• Evaluative
• Emotive
• Persuasive ??????
• Interrogative (questioning)
• Recreational (fun)
• Sometimes we might also offer vague promises in
  order to give ourselves flexibility.

19
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23
Humans routinely draw conclusions in situations.
Those conclusions are based on assumptions that
usually operate at an unconscious level.
?????? ???????
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555 feet
A Year of MEDLINE indexed journals
Washington Monument
25
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26
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27
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• How many original articles should a
• specialist read each week to remain
• up to date in his/her own field only ?
• 5
• 10
• 20
• 40
• 100
• The story is different for a generalist 17 /day!

Dr.S.Naserimoghaddam
28
????? ??? ?????? ?????? ?? ?? ???!

• A pervasive problem for primary care physicians
  attempting to appraise clinical information is
  the conflicting recommendations by experts.

Bloor M. Bishop Berkeley and the
adenotonsillectomy enigma an exploration of the
social construction of medical disposals.
Sociology 1976 10 4361.
EVIDENCE-BASED PRACTICE 2000
29
?? ???? ??????? ?? ???? ???? ????
100
r -0.54 plt0.001
. .. . . .... .
knowledge of current best care
...
... ...
50
... ..
.... ....
0
years since graduation

• Choudhry, Fletcher and Soumerai,
• Ann Intern Med 2005142260-73
• 94 of 62 studies found decreasing competence for
  at least some tasks, with increasing physician
  age.

30
?????? ?????? ?? ??? ???? ???????? ???? ????????!

• Scores inversely correlate with graduation year
  (Ramsey PG. JAMA 19912661103)
• Hypertension knowledge inversely correlates with
  graduation year (Sackett DL. Can med assoc Jnl
  1984130719)

31
??? ??????????(????????...) ?? ?? ???? ???
????????

• Traditional CME in a nice place with pleasant
  after lecture diversions is, unfortunately,
  completely ineffective in changing our behavior.

Davis DA, Thompson MA, Oxman AD, Haynes RB
Changing physician performance. A systematic
review of the effect of continuing medical
education strategies. JAMA 1995274700-5.
32
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33
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34
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• Percent of articles meeting quality criteria
• NEJM 12.6
• Ann Int Med 7.6
• JAMA 7.2
• Lancet 6.2
• BMJ 4.4
• Arch Int Med 2.4

35
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baseline
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• ?? ?????? ????? ???? ????? ??????? ???? ???? ???
  ??? ???? ???? ??? ??? ????? ???80 ?????? ?? 17
  ??? ??? ?? ?????? ??? ?????? ???? ????? ??
  ??????? ???? ???????!
• Protocols in UK neurology units - 80 still
  recommend bed rest after LP Serpell M, BMJ
  1998316170910evidence of harm available for
  17 years preceding...

Allen, Glasziou, Del Mar. Lancet, 1999
39
????? ??? ?????? ?? ??????

• Between 44,000 and 98,000 deaths due to medical
  errors
• Highway accidents 43,458
• Breast cancer 42,297
• AIDS 16,516

40
???????? ?????? ?????

• In Bates et al's study of adverse drug events at
  2 teaching hospitals in Boston
• 1 of the events were fatal,
• 12 were life-threatening,
• 30 were serious,
• 57 were significant.
• Of the adverse events classified as
  life-threatening or serious, 42 were
  preventable.
• Errors resulting in preventable adverse events
  occurred most often during ordering (56) and
  administering (24).

41
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  ????? ?????!

42
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43
Humans routinely draw conclusions in situations.
Those conclusions are based on assumptions that
usually operate at an unconscious level.
?????? ???????
???? ???????
44
?????? ???????

1. Ad Hominem (Argument To The Man)
2. Affirming The Consequent
3. Amazing Familiarity
4. Ambiguous Assertion
5. Appeal To Anonymous Authority
6. Appeal To Authority
7. Appeal To Coincidence
8. Appeal To Complexity
9. Appeal To False Authority
10. Appeal To Force
11. Appeal To Pity (Appeal to Sympathy, The Galileo
    Argument)
12. Appeal To Widespread Belief (Bandwagon Argument,
    Peer Pressure, Appeal To Common Practice)
13. Argument By Emotive Language (Appeal To The
    People)
14. Argument By Fast Talking
15. Argument By Generalization
16. Argument By Gibberish (Bafflement)
17. Argument By Half Truth (Suppressed Evidence)
18. Argument By Laziness (Argument By Uninformed
    Opinion)
19. Argument By Personal Charm

45
?????? ???????

1. Argument To The Future
2. Bad Analogy
3. Begging The Question (Assuming The Answer,
   Tautology)
4. Burden Of Proof
5. Causal Reductionism (Complex Cause)
6. Changing The Subject (Digression, Red Herring,
   Misdirection, False Emphasis)
7. Cliche Thinking
8. Common Sense
9. Complex Question (Tying)
10. Confusing Correlation And Causation
11. Disproof By Fallacy
12. Equivocation
13. Error Of Fact
14. Euphemism
15. Exception That Proves The Rule
16. Excluded Middle (False Dichotomy, Faulty Dilemma,
    Bifurcation)
17. Extended Analogy
18. Failure To State
19. Fallacy Of Composition

46
?????? ???????

1. Outdated Information
2. Pious Fraud
3. Poisoning The Wells
4. Psychogenetic Fallacy
5. Reductio Ad Absurdum
6. Reductive Fallacy (Oversimplification)
7. Reifying
8. Short Term Versus Long Term
9. Slippery Slope Fallacy (Camel's Nose)
10. Special Pleading (Stacking The Deck)
11. Statement Of Conversion
12. Stolen Concept
13. Straw Man (Fallacy Of Extension)
14. Two Wrongs Make A Right (Tu Quoque, You Too)
15. Weasel Wording
16. Recently added or modified fallacies
17. Ad Hominem (Argument To The Man) modified.
18. Equivocation modified.
19. Fallacy Of The Crucial Experiment added.

gt150!
47
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• ???? ???? X ????? ?? ??? ????? ????? ?????? ?????
  ????? ??????? ??????? ???? ?? ??? ??? (zn) ?????
  ????? ?? ??? ? ?? ????? ?? ?????? ?? ??? ??? ??
  ???? ?? ??? ? ??? ???? ???? ??? ?? ????. ????
  ?????? ?? ??????? ??? ?????? ?? ?? ??? ?? ?? ????
  ????? ?? ???.

Evidence Based Fallacy
50
???? P Q R????? ???? ???????
zinc???? ?????? ??
51
?????? ???/????

• This fallacy is based on an assumption that if
  something is now in practice, it ought to be so.
• Example "In our practice, the periodical
  examination for male patients over 50 years of
  age includes obtaining a chest radiograph.
• A chest radiograph ought to be an integral part
  of the periodic examination of healthy senior
  adults."

52
Humans routinely draw conclusions in situations.
Those conclusions are based on assumptions that
usually operate at an unconscious level.
?????? ???????
???? ???????
???? ??????
53
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• ?????????
• ?? ???
• ????? ?????

54
?????? ??????

1. anchoring
2. anthropic bias
3. anthropocentric bias
4. androocentric bias
5. attribution, attributional bias
6. availability error
7. Barnum effect
8. base rate neglect
9. behavioral confirmation
10. belief perseverance
11. bias blind spot
12. clustering illusion
13. confirmation bias
14. conjunction fallacy
15. contrast effect
16. cultural bias
17. dilution effect
18. disconfirmation bias
19. egocentric bias

55
?????? ??????

1. impact bias
2. inequity aversion
3. infrastructure bias
4. ingroup bias
5. just-world phenomenon
6. Kuleshov effect
7. Lake Wobegon effect
8. logical fallacy
9. loss aversion
10. media bias
11. memory bias
12. mere exposure effect
13. misinformation effect
14. negativity effect
15. negative perception of the color black
16. notational bias
17. outgroup homogeneity bias
18. overconfidence effect
19. pathetic fallacy

56
?????? ??????

1. reporting bias
2. risk-aversion
3. rosy retrospection
4. sample bias
5. selection bias
6. selective perception
7. self-deception
8. self-serving bias
9. spacing effect
10. statistical bias
11. status quo bias
12. sunk cost effects
13. tunnel vision
14. trait ascription bias
15. valence effect
16. Von Restorff effect
17. wishful thinking
18. worse-than-average effect
19. Zeigarnik effect

lt90, ok
57
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  ????? ?????
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  ????????..)????? ????
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  ????? ?????!

59
???? ???? ? ???? (????)

• In the West, logical????? and semantic clarity
  ?????? are among the most celebrated of the
  ideals of Reason.
• These ideas are associated with univocal
  definition guaranteeing unambiguous?? ?????
  usage.
• In this sense, the opposite of clarity is
  confusion a state of unarticulated ideas or
  feelings.

• In classical Eastern texts, allusive ???
  ??????and connotatively rich language is more
  highly prized than clarity, precision??? , and
  argumentative ????????rigor.
• We must attempt to avoid the Fallacy of the
  Perfect Dictionary

60
???? ???? ? ???????
Schön, D. (1987). Educating the reflective
practitioner Towards a new design for teaching
and learning in the professions, San Francisco
Jossey-Bass.
61
???? ???? ? ?????? ????

• When more than 400 senior HR (human resource)
  professionals were asked in a survey to name the
  most important skill their employees will need in
  the next five years, critical thinking ranked the
  highest surpassing innovation or the application
  of information technology.

Are They Really Ready to Work? Employers
Perspectives on the Basic Knowledge and Applied
Skills of New Entrants to the 21st Century US
Workforce (2006). Study conducted by The
Conference Board, Partnership for 21st Century
Skills 2 Hagemann, B. and Chartrand, J.M. (2009).
2009 Trends in Executive development A
Benchmark Report (Technical Report). Oklahoma
City Executive Development Associates.
62
???? ???? ? ??????? ???
63
???? ???? ? ??????? ???
64
????? ???? ???? ?? ???? ???? ??

• communication skills
• self-esteem
• collaborative learning
• Motivation
• Curiosity
• job skills for the future,

How to Prepare Students for a rapidly Changing
World by Richard Paul
65
??? ? ???? ????

• Just because you are intelligent or have great
  knowledge does not mean you can think critically.
  
• A profound genius may have the most irrational of
  beliefs or the most unreasonable of opinions.
• Critical thinking is about how we use our
  intelligence and knowledge to reach objective and
  rationale viewpoints.

Richard Paul 2006
66
????? ????? ???? ?? ?????

• ????? ????? ??????? ??? ?????? ????? ?????
  (TIMSS) ?? ???????? ? ???????? ?????? ?? ??? ??
  ?????? ????? ??? ?????? ???????? ?????? ??????
  (IEA) ????? ???? ??? ???? ?????? ?????? ????
  ?????? ?? ??? ????? ?????? ????? ? ?????  ? ??
  ????? ?? ????? ????? ?????? ?? ?????? ???? ??????
  ???? ???? ???? ????? ???.
• ????? ??????? ???????? ???? ???? ??????? ?????
  ????????? ?? ??? ???? ?? ?? ???? ???? ??? (??????
  1376)

67
????? ????? (?? ???? ?????? ?? ??? ?????????
??????? ?????)

• ??????? ???? ???? ??????? ?? ????????? ??? ????
  96/11 ? ?? ????????? ??? ??? 6/13 ? ?? ?????????
  ??? ??? 45/13 ???.
• ?????? ??????? ???? ?? ????? ?? ??? ? ???????
  ?????? ? ????? ??????? ????? ?????? ???? ???
  ????? ? ?? ?? ?????? ?????? ????? ???? ? ?? ??
  ?????? ? ???? ????? ? ???? ??????? ??????? ??? ?
  ????? ??????? ? ???? ?????? ??????? ?????.

68
What Critical Thinking Is Not

• Thinking critically is not thinking negatively
  with a predisposition to find fault or flaws.
• It is a neutral and unbiased process for
  evaluating claims or opinions, either someone
  elses or our own.
• Critical thinking is not intended to make people
  think alike.
• Additionally, there will always be differences in
  perception and basic emotional needs which
  prevent us from all thinking the same way.

69
????? ???? ???? ?? ????? ??????

• Better reasoning/thinking.
• Mastery of our thinking
• Better learning
• Creative thinking
• Better Communications
• Better decisions making
• Professional success

70
??? ?? ???? ???? ?? ?????? ???? ?????

• To teach physicians how to think.
• To teach physicians how to analyze.
• To teach physicians how to make judgments.
• To teach physicians how to reach conclusions.

71
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  ????? ?????
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  ????????..)????? ????
• 4-????? ????? ???? ???? ?? ????? ?? ??? ???? ????
  ????? ?????!

72

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• (???????? ????)

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  ??? ?????? ?? ???? ???
• ???????? ?????????? ???? ????? ???? ?? ????? ?
  ???? ????? ? ?????? ??? ?????.

74
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  ??? ? ????? ??? ?????? ???? ??? ?? ???? ???? ??
  ?? ??????.
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  ???? ???? ??? ?? ?????? ? ??????? ??????? ?? ????
  ???? ?? ????.

75
Humans routinely draw conclusions in situations.
Those conclusions are based on assumptions that
usually operate at an unconscious level.
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80

• part-2
• Argument

81

• ??????????? ???????

82
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  ???????? ?? ???? ????? ???? ?? ?????? ???? ????
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• Conclusion
• Premise
• ???? ??? ? ?????2008

83
Reasoning and Argument

• Reasoning is thinking directed toward reaching a
  conclusion. Ideally, it is structured by logic,
  as defined earlier.
• For example, one may say to oneself, "This
  70-year-old patient of mine has lung cancer, so
  he should stop smoking," thus inferring the
  conclusion that the patient should stop smoking
  from the diagnosis of lung cancer.

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architecture and building blocks of a classical
categorical syllogism

• Premises are statements of evidence.
• A conclusion is a statement that is supported by
  evidence.
• Inference is the "path from premises to
  conclusion

85
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86
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87
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88
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• . examples
• . statistics
• .definitions
• . background information
• . evidence

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91
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92

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93
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95
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96
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  ??????(knowing) ?? ???? ??? ? ????? ?????? ??????
  (Understanding) ?? ????.

97
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99
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  ????? ?? ?? ????? ???? ??? ????.

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Kinds of Reasons

• different kinds of reason depends on the kind of
  issue.
• Descriptive argument
• Prescriptive argument

101
descriptive argument
evidence specific information that someone uses
to furnish "proof" for something she is trying to
claim is true

• . Includes
• the facts
• research findings
• examples from real life
• statistics
• appeals to experts and authorities
• personal testimonials
• metaphors and analogies

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Prescriptive arguments

• no evidence is presented
• Reasons are typically either
• general, prescriptive
  statements,
• or descriptive beliefs or
  principles .

103
Note that no evidence is presented The reasons
are general principles that indicate the writer's
view
104
prescriptive issues

• Ethical, or moral.
• raise questions about what is right or wrong,
  desirable or undesirable, good .or bad
• Social controversies are often prescriptive
  issues.

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106
References

• The Foundations Of Analytic Thinking How To Take
  Thinking Apart And What To Look For When You
  DoBy Dr. Linda Elder and Dr. Richard Paul
• Critical Thinking Teaching College and
  University Students to Think Critically and
  Evaluate By G.Haskin
• Critical Thinking What It Is and Why It Counts
  By Peter A. Facione1998
• Critical Thinking By Robin Wood 2002
• Critical Thinking Skills in the College
  Curriculum The Academic Senate for California
  Community Colleges April 1988