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 *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html