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From:
Barbara Wilson-Clay <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Thu, 17 Feb 2000 11:00:21 -0600
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I am interested in the evidence based discussion, and agree with Kathleen
Auerbach's fine explanation that 1st we don't harm anyone, and then we use
our experience to develop protocols to test our beliefs to see if they are
scientifically valid.  I was not trained as a scientist, and yet, have tried
to learn to think like one.  In other words, it is important to ask
questions, to challenge assumptions, and to try to understand HOW and WHY
things work.  Then it is important to put these ideas on the table and
debate them.  I don't know that we are any nastier to each other than
scientists in other fields -- altho that may not be much of a recommendation
:)  I think that people are often prickly when defending ideas and beliefs.
What I try to do is be open minded.  If you can prove your position and back
it up, I have to consider changing my practice.  To cling to beliefs that
are shown to be baseless has the potential to violate the 1st "do no harm"
rule.

To quote from an article on this very subject (Enkin,M.  Effective Care in
Pregnancy and Childbirth:  The Cochrane Pregnancy and Childbirth Database, J
Perinatal Ed 1995, 4(4):23-35.)

"Unless the validity of informal impressions about the effects of care is
assessed by formal evaluation, effective forms of care will not be
recognized as such  and will not be brought into use as promptly as
possible, while ineffective or harmful forms of care will not be detected
efficiently, and may do harm on a wider scale than necessary...  Medical
journals are full of formal studies that attempt to address uncertainties
about the effects of aspects of care during pregnancy and childbirth.
However, not all of these studies provide reliable information.  If we wish
to make valid judgements we must pay careful attention to the strengths and
weaknesses of the methods used by the investigators.  In this way we can
rationally select those studies that are most likely to provide useful
evidence.  Sometimes, but certainly not always, comparison with past
experience is enough to make a valid assessment of the effects of care."

So I think this supports the idea that we are always testing experience
against research in a kind of dynamic way that really challenges our best
thinking.  This article goes on to describe the diff. between case reports,
uncontrolled case series, and individual experience without a proper
comparison group.  It warns about the variety of biases which either "mask
real differences or suggest that there are differences that in fact are not
true."    Then it describes randomization as the only way to guarantee that
the comparison groups are chosen fairly, by chance rather than by biased
source of selection.  This is the gold standard for providing the most valid
information about the effects of care.  When we don;t have this, we must
look to weaker forms of evidence on which to base clinical decisions.
Because we are a new science, we often lack evidence, and must take our best
shots.

So  what we've learned from experience must be shared with our peers to test
out whether others have observed this too.  I see this as a starting point
for research.  It's very exciting to be in a field where so much normative
work has yet to be done.  There is lots of work for us all.  I think the
journal club discussion soon to begin on Lactnet will be yet another way to
tap into this dynamic interplay between experience and research.

Shall we expect this debate  always to be delicate?  Maybe that's not
possible.  But while the debate may become robust and even heated, it should
be polite in terms of not attacking the PERSON.  We must continue to
challenge IDEAS and TECHNIQUES.

Barbara Wilson-Clay, BSEd, IBCLC
Austin Lactation Associates, Austin, Texas
http://www.lactnews.com

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