Why did no one ask board certified professional Industrial Hygienists these questions about masking? They are the actual experts when it comes to PPE. MDs are not experts in PPE. At best they follow tradition and not much else. Do do what they have been told to do by people who pretend to be the experts, when all they are doing is doing what has always been done. Mask or not mask, or what kind of mask, would have been settled very quickly if the actual experts were consulted. Remember this for the next time.
Thanks for this! I think the difference between risk assessment and risk management is seldom articulated and I believe many do not see these things as different. I think that at a policy level there is far too much risk management without risk assessment. A personal beef is someone who says, "We are very risk tolerant or we are very risk averse" when they clearly do not understand what the risk actually is and are just adjusting the message for their audience at the time.
What happened during the pandemic was that policy makers did not adjust their risk management in accordance with risk assessment, or in fact made no risk assessments at all and skipped straight to risk management.
Mealy-mouthed social science commentary will never convince me or anyone else thinking logically that masking was statistically beneficial. Nice try.
I am a primary internist in a rural setting with at least 7 other physicians in my town, maybe 20 in the whole county of 55,000. I stopped masking in January 2021. My m/m rates were no different, and in some cases better, than all other physicians...especially the haz-mat suit physicians who lost many patients to me bc they (the patients) saw how I govern my life with logic and not fear.
We have a lot more data than from your town—we have data by state and county over the duration of the pandemic in which everyone eventually got Covid!! Masks clearly mitigated spread prior to Omicron. Getting vaccinated and boosted was clearly safer than going for natural immunity. So masking worked in that it slowed spread so that people could get vaccinated and boosted until a less severe variant dominated. If the vaccines didn’t mitigate severity masking would have still made sense because Omicron was the best time to acquire natural immunity. Masking would only not make sense if Covid variants got stronger and no vaccines were being developed in which case we should have delayed enough for the health care community to develop best practices to treat Covid and then let it rip until Covid wards filled up and rinse and repeat.
You need to get updated information. You are still living in 2021 and believing the lies told to you by those with motives other than your health and well being.
1. The shots are not vaccines. 2. They are far from safe and effective. Of course no one was told what they were effective against. They were not effective at all against prevention or transmission. At best, and there is doubt about this, that they moderated symptoms. Given the very high rate of major adverse side affects, including death, safe is also questionable.
Hawaii has low natural immunity with high vaccinated immunity and the vaccines held against Omicron and Hawaii hasn’t had high excess deaths from some unknown cause the last several years which would be from the vaccines.
All of this is fine, except it's glaringly clear the current masking issue is a direct result of the COVID terrorism propaganda that convinced millions of people the virus was worse than the Black Death. The Maskers are specifically doing so to avoid contracting SARS-CoV-2, demanding others cover up where they will themselves admit they never needed it before. A case might perhaps be made it's a form of PTSD, as they firmly believe the "pandemic" is still in full swing, and they've been abandoned by the people who should be protecting them from certain death. I'm not exaggerating.
There is no uncertainty. Masks are not something new that has only existed since 2019. They are used for various purposes, from diving to astronautics, in all kinds of industries and have been seriously researched and used for about a hundred years, and many of these purposes are far more demanding than protection from viral aerosols. There are approximately 20 levels of protection in total. Serious use must ensure (1) that the appropriate mask is used (2) that it is used correctly (3) that it is used consistently.
If someone claims that masks GENERALLY don't protect, and the only thing they've tested are FFP2 masks (so roughly level 4 masks out of 20 levels) and haven't even checked that the masks are being used properly and consistently, they're either insane or malicious.
I watched a movie from 2018 that took place in China and a plot point involved an American getting sick on a bus and the Chinese passengers gave her a mask and demanded she wear it.
In the Army, we train to put on our promasks (protective mask) in 9 seconds. That includes checking for hermetically sealed mask. Then you have 6 seconds to put the plastic "hood/head poncho" over your shoulder. And this is for chemical and biological agents. that are roughly and order of magnitude bigger than viruses. If the military thought that a surgical masks could protect soldiers from bacterial/chemical agents, they would NEVER have spent the money on promasks. How can something that has gaps that are 3 orders of magnitude bigger than a virus stop it?
We have data by county and state—masks worked. Now they weren’t a silver bullet but nothing was not even the vaccines. But people also needed to wear glasses and a hat and make a concerted effort to avoid other people’s droplets. But because they weren’t a silver bullet and like you say people could wear better protection it was stupid for people to be mask Nazis because anyone outside of their home during regular hours is taking a risk. Now when we had elderly only hours people should have been more careful.
As a former critical care nurse who worked at an academic medical center, I am perplexed. In my experience, before Covid we never wore surgical masks in the rooms of patients with viral infections. Every box of surgical masks had a disclaimer on it: "Does not prevent viral transmission", or similar wording. I have not seen this disclaimer since the advent of Covid, and I am mystified...did the masks suddenly become impervious to viruses?
I did read that but the Cochrane reviews are the gold standard right? it was only branded "controversial" BECAUSE it did not support what some in the government were saying. Yes, randomized control studies are the highest quality evidence. And so if you mix high and low quality data in a meta review, it will skew the results. Their stated objective for doing this review is frankly a bit of nonsense. obviously just to create a publication that will be cited in the "mask debate". There is literally no "need for a new review" - as they claim! This is BS science. Instead of explaining why the Cochrane review is the gold standard and should be trusted, the claim is different and this undermines science.
This plays to the exact politicization of data and science that the authors claim is important. There is nothing wrong with the Cochrane review. Except that the results go against some medical advice because they only looked at high quality studies. Their claims in this paper that "Sixth, while there is much evidence that masks are not generally harmful to the general population..." is 100% incorrect.
The idea that there's nothing wrong with the Cochrane review is not universally shared. Greenhalgh et al's review does not take as a given that only RCTs should be included. Greenhalgh literally wrote the book on evidence based medicine so her perspective on why RCT evidence is necessary but not sufficient in this case is worth reading: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003266
I read this link you posted but I'm not sure why we should take her research as being more correct than Cochrane. can you elaborate? All of the criticism seems frankly political (i.e. they didn't support the public health czars official statements about masking and therefore were vilified).
Much of what is written of the introduction of that piece is not (in my view) political as much as making the case for when RCT evidence is useful (i.e. therapeutics) and when they're not (i.e. complex interventions dependent on multiple factors for effectiveness). There are two paragraphs in particular that are worth emphasizing:
"Whilst evidence-based medicine recognises that study designs must reflect the nature of question (randomized trials, for example, are preferred only for therapy questions [13]), even senior scientists sometimes over-apply its hierarchy of evidence. An interdisciplinary group of scholars from the UK’s prestigious Royal Society recently reviewed the use of face masks by the general public, drawing on evidence from laboratory science, mathematical modelling and policy studies [14]. The report was criticised by epidemiologists for being “non-systematic” and for recommending policy action in the absence of a quantitative estimate of effect size from robust randomized controlled trials [15]."
"Such criticisms appear to make two questionable assumptions: first, that the precise quantification of impact from this kind of intervention is both possible and desirable, and second, that unless we have randomized trial evidence, we should do nothing."
That critique does not sound political to me, but gets to the scientific question of what evidence speaks to which questions. And that last part, about how in the absence of RCT evidence "we should do nothing" is 1. a common assumption on Sensible Medicine and 2. a risk management strategy that is neither universally shared nor acknowledged as imposing ones values over others'.
This speaks to your point that the Cochrane review "was only branded "controversial" BECAUSE it did not support what some in the government were saying." That is not what Greenhalgh and colleagues are saying. If you're open to reading more on this topic, Greenhalgh has written quite a lot. She's an expert in evidence based medicine and a lucid writer. It is worth the time.
The “highest quality data” is the CDC data by county and state over the entirety of the pandemic. Going by Cochrane when you have actual data of that magnitude would be like discussing Peyton Manning’s NFL career using his college statistics.
I think masking touches on a sore spot and is a broader issue for a lot of people who feel they were misled (which they were) by the policies instituted by the government during the pandemic. There were also places where toddlers were forced to wear masks even when a lot of them kept trying to remove them. It was horrible to watch. As far as in a hospital setting, I think it should be up to the individual doctors and patients alike. With regard to mammography, I had an OB/GYN, who kept pushing me to the point I felt it was inappropriate. I was uncomfortable with the method used. I went to a different doctor who suggested I could instead have an ultrasound, which is what I did. So basically I think these things should be between patient and doctor and if you are not happy with, your patient or your doctor then you are always free to find someone else. I also think it's important for us all to remember that science is always changing. sabrinalabow.substack.com
Wearing a face diaper serves no other purpose than fear mongering and displaying one's germophobia. So no, such anti-science positions have no business in a healthcare setting!
I’m confused…the Cochrane review found no clear evidence for efficacy of masks. Since it is long considered the gold standard in medical reviews/meta analysis, why are you pretending the question is open? The review of course was disparaged in a political way but as scientists we should defend science.
We have data by county and state with different counties and states implementing different mitigation measures. Do you seriously think it’s just a coincidence that Arizona, the largest state with the fewest mitigation measures in 2020, has the highest Covid death rate. While Hawaii, the state that avoided the initial wave while have the strongest mitigation measures, has the lowest Covid death rate…that’s all a coincidence?? Everyone in Hawaii eventually got Covid from mainlanders and yet the vaccines held. And you can see that masks made a difference by looking at the county level because the major urban Democrat counties in the southeast defied mask bans and they have low Covid death rates. Generally the counties with the lowest death rates in the southeast are very wealthy Republican counties that have high vaccination rates and were able to Zoom prior to the availability of the vaccines.
Reading it looks like they only included 2 mask RCTs during Covid- 1 showed no benefit in Denmark. The other was the Bangladesh crappy study. Every other RCT was prior to Covid and most showed no benefit.
Yes, that's the reading of RCTs, but the point of the Greenhalgh review is that they do not take as a given that only RCTs should be included. Greenhalgh literally wrote the book on evidence based medicine so her perspective on why RCT evidence is necessary but not sufficient in this case is worth reading: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003266
Way too long and convoluted. When we have to trust the social “sciences” we’re dead. That Dr. Fauci never funded a masking study in America speaks loudly that they don’t work for viral respiratory illnesses.
This framework of “the science” Vs “the trade-offs” reminds me of the recent pieces on this site about the Sackett pillars of EBM, and the very useful highlight that the science pillar co-exists with pt comorbidities and pt preferences. In that paradigm, practicing EBM requires a synthesis of all 3 aspects (and IMO argues against many of the one-size-fits-all cookbook proclivities of latter day guideline writers).
In that vein, however, it would appear that the “assessment” Vs “management” duality would argue against wide reaching “policy” declarations, which are even more “cookbook” than mere guideline recommendations.
I would submit that, where “guidelines” should holistically reflect the sum total of “evidence based”, so too should “policies”. And sometimes, neither realm does a very good job of fulfilling those ideals.
In treating the individual patient, the patient’s values and preferences interact with the scientific evidence for and against a treatment. The sociological analysis adds a society’s values and preferences to those of the individual. In either case, values and preferences should be downstream from the scientific evidence. Neither a group nor an individual can make good decisions without knowing the evidence. Unfortunately, we rarely provide a view of the evidence.
Take the example of screening mammography. A woman considering this should know “what is the likelihood that having the test will reduce my likelihood of dying from breast cancer?” And should also know “what is the likelihood that having the test will reduce my likelihood of dying, period?” These statistics are called “the number needed to screen to prevent one death from the condition of interest” and “the number needed to screen to prevent one death from any condition.” Correct me if I am wrong, but I remember that the former number is in range of 500 and the latter number is close to infinity. Cancer screening in general is promoted by claims that screenings reduce disease-specific mortality; we rarely are given information on all-cause mortality. Patients cannot make informed decisions about screening until they receive this information.
The same principle applies to treating. “Drug X reduces your chance of dying from your myeloma by 30%.” That sort of statistic incents doctors to prescribe, patients to accept, and insurance companies to pay for the treatment. And often that is as much information as doctors get from the Abstract section of a medical article. Suppose Drug X reduces my risk of dying from myeloma from 10% to 7%. That is a drop of 30% in relative terms, but 3% in absolute terms. And suppose some unrecognized side effect of treatment adds back that 3% - my all-cause mortality does not drop a bit.
An acceptable informed consent process would tell a patient “If you take this treatment for XX months, your risk of dying from the disease probably drops from 10% to 7%, but your risk of dying from any cause is 20% without treatment and 19% with treatment; your likelihood of suffering severe side effects from treatment is XX%.” The stakes are much lower in making decisions about taking an antibiotic for sinusitis, but the principle should be the same.
Bottom line: patients cannot make treatment decisions that reflect their values and preferences because they are not provided the scientific data they need, and doctors are hard-pressed to provide the correct and relevant data because authors and reviewers and standards writers show little interest in this data.
Cochrane follow up discussion -> https://trusttheevidence.substack.com/p/the-cochrane-editors-comments
Why did no one ask board certified professional Industrial Hygienists these questions about masking? They are the actual experts when it comes to PPE. MDs are not experts in PPE. At best they follow tradition and not much else. Do do what they have been told to do by people who pretend to be the experts, when all they are doing is doing what has always been done. Mask or not mask, or what kind of mask, would have been settled very quickly if the actual experts were consulted. Remember this for the next time.
Great! Very integral way of looking at it. I needed to read this today. Keep writing in this space.
Thanks for this! I think the difference between risk assessment and risk management is seldom articulated and I believe many do not see these things as different. I think that at a policy level there is far too much risk management without risk assessment. A personal beef is someone who says, "We are very risk tolerant or we are very risk averse" when they clearly do not understand what the risk actually is and are just adjusting the message for their audience at the time.
What happened during the pandemic was that policy makers did not adjust their risk management in accordance with risk assessment, or in fact made no risk assessments at all and skipped straight to risk management.
Mealy-mouthed social science commentary will never convince me or anyone else thinking logically that masking was statistically beneficial. Nice try.
I am a primary internist in a rural setting with at least 7 other physicians in my town, maybe 20 in the whole county of 55,000. I stopped masking in January 2021. My m/m rates were no different, and in some cases better, than all other physicians...especially the haz-mat suit physicians who lost many patients to me bc they (the patients) saw how I govern my life with logic and not fear.
We have a lot more data than from your town—we have data by state and county over the duration of the pandemic in which everyone eventually got Covid!! Masks clearly mitigated spread prior to Omicron. Getting vaccinated and boosted was clearly safer than going for natural immunity. So masking worked in that it slowed spread so that people could get vaccinated and boosted until a less severe variant dominated. If the vaccines didn’t mitigate severity masking would have still made sense because Omicron was the best time to acquire natural immunity. Masking would only not make sense if Covid variants got stronger and no vaccines were being developed in which case we should have delayed enough for the health care community to develop best practices to treat Covid and then let it rip until Covid wards filled up and rinse and repeat.
You need to get updated information. You are still living in 2021 and believing the lies told to you by those with motives other than your health and well being.
1. The shots are not vaccines. 2. They are far from safe and effective. Of course no one was told what they were effective against. They were not effective at all against prevention or transmission. At best, and there is doubt about this, that they moderated symptoms. Given the very high rate of major adverse side affects, including death, safe is also questionable.
Hawaii has low natural immunity with high vaccinated immunity and the vaccines held against Omicron and Hawaii hasn’t had high excess deaths from some unknown cause the last several years which would be from the vaccines.
All of this is fine, except it's glaringly clear the current masking issue is a direct result of the COVID terrorism propaganda that convinced millions of people the virus was worse than the Black Death. The Maskers are specifically doing so to avoid contracting SARS-CoV-2, demanding others cover up where they will themselves admit they never needed it before. A case might perhaps be made it's a form of PTSD, as they firmly believe the "pandemic" is still in full swing, and they've been abandoned by the people who should be protecting them from certain death. I'm not exaggerating.
There is no uncertainty. Masks are not something new that has only existed since 2019. They are used for various purposes, from diving to astronautics, in all kinds of industries and have been seriously researched and used for about a hundred years, and many of these purposes are far more demanding than protection from viral aerosols. There are approximately 20 levels of protection in total. Serious use must ensure (1) that the appropriate mask is used (2) that it is used correctly (3) that it is used consistently.
If someone claims that masks GENERALLY don't protect, and the only thing they've tested are FFP2 masks (so roughly level 4 masks out of 20 levels) and haven't even checked that the masks are being used properly and consistently, they're either insane or malicious.
I watched a movie from 2018 that took place in China and a plot point involved an American getting sick on a bus and the Chinese passengers gave her a mask and demanded she wear it.
The intro basically is so embarrassing as to negate the value of reading the rest of the article.
" First, let’s agree that there is uncertainty around the efficacy of masking.
FALSE there is zero actual evidence for face diapering.
1. Masking in healthcare facilities reduces the transmission of respiratory infections,
FALSE, no one healthcare in the West used to face diaper during ILI season, and countries/cultures who do so not show reduced rates of ILIs.
2. COVID carries less risk now than it did in 2020,
MISLEADING as it implies early covid was something to fear. It never was. Actual covid deaths were not significantly worse than other large flu years.
3. People do still get sick and die from COVID (though the question of risk of Long COVID with new or recurrent infection remains uncertain).
MISLEADING, still pushing fear of covid, and THAT is in and of itself unhealthy.
In the Army, we train to put on our promasks (protective mask) in 9 seconds. That includes checking for hermetically sealed mask. Then you have 6 seconds to put the plastic "hood/head poncho" over your shoulder. And this is for chemical and biological agents. that are roughly and order of magnitude bigger than viruses. If the military thought that a surgical masks could protect soldiers from bacterial/chemical agents, they would NEVER have spent the money on promasks. How can something that has gaps that are 3 orders of magnitude bigger than a virus stop it?
We have data by county and state—masks worked. Now they weren’t a silver bullet but nothing was not even the vaccines. But people also needed to wear glasses and a hat and make a concerted effort to avoid other people’s droplets. But because they weren’t a silver bullet and like you say people could wear better protection it was stupid for people to be mask Nazis because anyone outside of their home during regular hours is taking a risk. Now when we had elderly only hours people should have been more careful.
It's worse than what you portray. People wearing face diapers have entire centimetres of gap, let alone the pore size!!!
As a former critical care nurse who worked at an academic medical center, I am perplexed. In my experience, before Covid we never wore surgical masks in the rooms of patients with viral infections. Every box of surgical masks had a disclaimer on it: "Does not prevent viral transmission", or similar wording. I have not seen this disclaimer since the advent of Covid, and I am mystified...did the masks suddenly become impervious to viruses?
I did read that but the Cochrane reviews are the gold standard right? it was only branded "controversial" BECAUSE it did not support what some in the government were saying. Yes, randomized control studies are the highest quality evidence. And so if you mix high and low quality data in a meta review, it will skew the results. Their stated objective for doing this review is frankly a bit of nonsense. obviously just to create a publication that will be cited in the "mask debate". There is literally no "need for a new review" - as they claim! This is BS science. Instead of explaining why the Cochrane review is the gold standard and should be trusted, the claim is different and this undermines science.
This plays to the exact politicization of data and science that the authors claim is important. There is nothing wrong with the Cochrane review. Except that the results go against some medical advice because they only looked at high quality studies. Their claims in this paper that "Sixth, while there is much evidence that masks are not generally harmful to the general population..." is 100% incorrect.
There is plenty of data indicating contraindications for long term mask wearing (in non medical settings) - e.g. https://www.cell.com/heliyon/pdf/S2405-8440(23)01324-5.pdf which suggests that masks can lead to chronic carbon dioxide levels, increased blood pressure and even impaired cognitive function (https://clinmedjournals.org/articles/jide/journal-of-infectious-diseases-and-epidemiology-jide-6-130.php?jid=jide)
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006207.pub6/full
The idea that there's nothing wrong with the Cochrane review is not universally shared. Greenhalgh et al's review does not take as a given that only RCTs should be included. Greenhalgh literally wrote the book on evidence based medicine so her perspective on why RCT evidence is necessary but not sufficient in this case is worth reading: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003266
I read this link you posted but I'm not sure why we should take her research as being more correct than Cochrane. can you elaborate? All of the criticism seems frankly political (i.e. they didn't support the public health czars official statements about masking and therefore were vilified).
Much of what is written of the introduction of that piece is not (in my view) political as much as making the case for when RCT evidence is useful (i.e. therapeutics) and when they're not (i.e. complex interventions dependent on multiple factors for effectiveness). There are two paragraphs in particular that are worth emphasizing:
"Whilst evidence-based medicine recognises that study designs must reflect the nature of question (randomized trials, for example, are preferred only for therapy questions [13]), even senior scientists sometimes over-apply its hierarchy of evidence. An interdisciplinary group of scholars from the UK’s prestigious Royal Society recently reviewed the use of face masks by the general public, drawing on evidence from laboratory science, mathematical modelling and policy studies [14]. The report was criticised by epidemiologists for being “non-systematic” and for recommending policy action in the absence of a quantitative estimate of effect size from robust randomized controlled trials [15]."
"Such criticisms appear to make two questionable assumptions: first, that the precise quantification of impact from this kind of intervention is both possible and desirable, and second, that unless we have randomized trial evidence, we should do nothing."
That critique does not sound political to me, but gets to the scientific question of what evidence speaks to which questions. And that last part, about how in the absence of RCT evidence "we should do nothing" is 1. a common assumption on Sensible Medicine and 2. a risk management strategy that is neither universally shared nor acknowledged as imposing ones values over others'.
This speaks to your point that the Cochrane review "was only branded "controversial" BECAUSE it did not support what some in the government were saying." That is not what Greenhalgh and colleagues are saying. If you're open to reading more on this topic, Greenhalgh has written quite a lot. She's an expert in evidence based medicine and a lucid writer. It is worth the time.
The “highest quality data” is the CDC data by county and state over the entirety of the pandemic. Going by Cochrane when you have actual data of that magnitude would be like discussing Peyton Manning’s NFL career using his college statistics.
I think masking touches on a sore spot and is a broader issue for a lot of people who feel they were misled (which they were) by the policies instituted by the government during the pandemic. There were also places where toddlers were forced to wear masks even when a lot of them kept trying to remove them. It was horrible to watch. As far as in a hospital setting, I think it should be up to the individual doctors and patients alike. With regard to mammography, I had an OB/GYN, who kept pushing me to the point I felt it was inappropriate. I was uncomfortable with the method used. I went to a different doctor who suggested I could instead have an ultrasound, which is what I did. So basically I think these things should be between patient and doctor and if you are not happy with, your patient or your doctor then you are always free to find someone else. I also think it's important for us all to remember that science is always changing. sabrinalabow.substack.com
Wearing a face diaper serves no other purpose than fear mongering and displaying one's germophobia. So no, such anti-science positions have no business in a healthcare setting!
I’m confused…the Cochrane review found no clear evidence for efficacy of masks. Since it is long considered the gold standard in medical reviews/meta analysis, why are you pretending the question is open? The review of course was disparaged in a political way but as scientists we should defend science.
We have data by county and state with different counties and states implementing different mitigation measures. Do you seriously think it’s just a coincidence that Arizona, the largest state with the fewest mitigation measures in 2020, has the highest Covid death rate. While Hawaii, the state that avoided the initial wave while have the strongest mitigation measures, has the lowest Covid death rate…that’s all a coincidence?? Everyone in Hawaii eventually got Covid from mainlanders and yet the vaccines held. And you can see that masks made a difference by looking at the county level because the major urban Democrat counties in the southeast defied mask bans and they have low Covid death rates. Generally the counties with the lowest death rates in the southeast are very wealthy Republican counties that have high vaccination rates and were able to Zoom prior to the availability of the vaccines.
I recommend following the link in the article to the comprehensive review published in late May by Trisha Greenhalgh and colleagues.
Reading it looks like they only included 2 mask RCTs during Covid- 1 showed no benefit in Denmark. The other was the Bangladesh crappy study. Every other RCT was prior to Covid and most showed no benefit.
Yes, that's the reading of RCTs, but the point of the Greenhalgh review is that they do not take as a given that only RCTs should be included. Greenhalgh literally wrote the book on evidence based medicine so her perspective on why RCT evidence is necessary but not sufficient in this case is worth reading: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003266
Way too long and convoluted. When we have to trust the social “sciences” we’re dead. That Dr. Fauci never funded a masking study in America speaks loudly that they don’t work for viral respiratory illnesses.
Very interesting perspective. Thanks for this.
This framework of “the science” Vs “the trade-offs” reminds me of the recent pieces on this site about the Sackett pillars of EBM, and the very useful highlight that the science pillar co-exists with pt comorbidities and pt preferences. In that paradigm, practicing EBM requires a synthesis of all 3 aspects (and IMO argues against many of the one-size-fits-all cookbook proclivities of latter day guideline writers).
In that vein, however, it would appear that the “assessment” Vs “management” duality would argue against wide reaching “policy” declarations, which are even more “cookbook” than mere guideline recommendations.
I would submit that, where “guidelines” should holistically reflect the sum total of “evidence based”, so too should “policies”. And sometimes, neither realm does a very good job of fulfilling those ideals.
In treating the individual patient, the patient’s values and preferences interact with the scientific evidence for and against a treatment. The sociological analysis adds a society’s values and preferences to those of the individual. In either case, values and preferences should be downstream from the scientific evidence. Neither a group nor an individual can make good decisions without knowing the evidence. Unfortunately, we rarely provide a view of the evidence.
Take the example of screening mammography. A woman considering this should know “what is the likelihood that having the test will reduce my likelihood of dying from breast cancer?” And should also know “what is the likelihood that having the test will reduce my likelihood of dying, period?” These statistics are called “the number needed to screen to prevent one death from the condition of interest” and “the number needed to screen to prevent one death from any condition.” Correct me if I am wrong, but I remember that the former number is in range of 500 and the latter number is close to infinity. Cancer screening in general is promoted by claims that screenings reduce disease-specific mortality; we rarely are given information on all-cause mortality. Patients cannot make informed decisions about screening until they receive this information.
The same principle applies to treating. “Drug X reduces your chance of dying from your myeloma by 30%.” That sort of statistic incents doctors to prescribe, patients to accept, and insurance companies to pay for the treatment. And often that is as much information as doctors get from the Abstract section of a medical article. Suppose Drug X reduces my risk of dying from myeloma from 10% to 7%. That is a drop of 30% in relative terms, but 3% in absolute terms. And suppose some unrecognized side effect of treatment adds back that 3% - my all-cause mortality does not drop a bit.
An acceptable informed consent process would tell a patient “If you take this treatment for XX months, your risk of dying from the disease probably drops from 10% to 7%, but your risk of dying from any cause is 20% without treatment and 19% with treatment; your likelihood of suffering severe side effects from treatment is XX%.” The stakes are much lower in making decisions about taking an antibiotic for sinusitis, but the principle should be the same.
Bottom line: patients cannot make treatment decisions that reflect their values and preferences because they are not provided the scientific data they need, and doctors are hard-pressed to provide the correct and relevant data because authors and reviewers and standards writers show little interest in this data.