Off the Desk - thoughts in development: When is an intervention a parachute intervention and not really amendable to the rigid strictures of empiricism proposed by evidence based practice…. And what does it mean when an intervention is not a parachute intervention?
Well, I suppose I work with parachutes in the arena of the soma / psyche distinction but the intervention of proclamation is only effective / affective with the effectual work of the Paracletos (Holy Spirit). Thus, the secondary agent speaks the word and the Spirit does the work (Romas 10.8-14).
On another note: I do enjoy a bit of sarcasm to illustrate a point; I took a graduate course in sarcasm and aced the course.
Sounds like the graduate course I took that taught me “correlation does not imply causation” - I still don’t know whether that course caused me to understand that concept, or if understanding that concept is simply correlated with the course.
Related to our recent discussion on salvation (universal or limited) - there’s a need for the universalist to accept that the parachute can open (effectual work of the Paracletos) after death.
Still digesting this, including why we gravitate towards silos (as PT's or anything else), and will return to it again in the coming days - good stuff so to speak. In the meantime, I thought I would pass along a couple of studies on parachutes - two in support of your thesis, and one against, but I doubt it will change your view on parachutes or your desire for life-saving interventions (it did not for me, but rather it gave me a physiologic response of anxiety). As one would expect, in 2003 Smith and Pell reported they found no RCT's in their systematic review to see if parachutes reduced the risk of death or serious injury (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/). However, there was an RCT published in 2015 showing that parachutes do not reduce the risk of death or major injury (https://www.bmj.com/content/363/bmj.k5094), but it can't be extrapolated to higher elevations. Most interestingly, in 2016 there was a self-published case study on jumping from 25,000' without a parachute or wingsuit which was successful (https://youtu.be/Xz2W_QC5vKs) but I don't think it would be ideal for a larger-scale study as most people would probably have the same response I did watching it.
Thanks David! Great additions to the thought experiment! The case series on YouTube is interesting as an example of alternative interventions. The intervention condition - parachutes - had 3 subjects. The control condition - a huge net - had one subject. In this case series everyone had an intervention and it was comparative. There’s certainly a need for studying alternatives. When studying alternatives the reasonableness of the alternative should rationally (not empirically) be considered and the probability of success should be weighed. Here even the empiricist Bradford Hill (of Hill’s Criteria of Causation) has a rational consideration - the plausibility of the causal factor. It is plausible that a net would be effective, assuming the person falling is capable to hitting the net. But I agree with you - not many people would find the net reasonable in terms of someone’s ability to hit the target! I guess an analogy could be drawn to a recent systematic review I read on the Nordic hamstring exercises to reduce the risk of hamstring injury in athletes (https://bjsm.bmj.com/content/49/6/349.short). Turns out the reduction in risk requires people actual do the exercises (hit the net so to speak). The papers you cite may be a bit more extreme attacks on EBP - but I admit to only having read the abstracts. I think using parachute interventions to try to argue against EBP for non parachute interventions is a slippery slope. I think when it comes to evidence for practice we need to be more agile than the current “pyramid” may allow - or perhaps I just see that the pyramid is interpreted too strictly by some people. This reminds me of how even the American Statistical Association wants to completely avoid use of the p-value and terminology related to its interpretation in hypothesis testing. This over reaction is not because the p-value doesn’t measure exactly what it is supposed to measure. It’s because people get overly rigorous about it. So avoid mis-use, we must stop using. Why either/or? Why not both/and? Why not a mix of rationalism and realism and pragmatism with empiricism regarding evidence?
The silo’s - yes, that’s a quandary. I had an adjunct faculty once tell our students just to “bear with it” while learning in courses that “would not be needed” when they were practicing where they wanted to practice (outpatient orthopedics). I was very dismayed and had to respond. Have you read: David Epstein: Range: Why Generalists Triumph in a Specialized World? https://davidepstein.com/the-range/
Upon re-reading my post above, there’s one more point to make here. Even if an intervention that saves a life is only effective a small amount of the time (i.e. CPR or defibrillation), since non intervention is clearly less effective then a small efficacy, it is still, relatively, largely effective. In other words, if my heart stops beating please do CPR even though the odds are low, because the odds of not doing it are lower.
Well, I suppose I work with parachutes in the arena of the soma / psyche distinction but the intervention of proclamation is only effective / affective with the effectual work of the Paracletos (Holy Spirit). Thus, the secondary agent speaks the word and the Spirit does the work (Romas 10.8-14).
On another note: I do enjoy a bit of sarcasm to illustrate a point; I took a graduate course in sarcasm and aced the course.
Sounds like the graduate course I took that taught me “correlation does not imply causation” - I still don’t know whether that course caused me to understand that concept, or if understanding that concept is simply correlated with the course.
Related to our recent discussion on salvation (universal or limited) - there’s a need for the universalist to accept that the parachute can open (effectual work of the Paracletos) after death.
Hi Sean,
Still digesting this, including why we gravitate towards silos (as PT's or anything else), and will return to it again in the coming days - good stuff so to speak. In the meantime, I thought I would pass along a couple of studies on parachutes - two in support of your thesis, and one against, but I doubt it will change your view on parachutes or your desire for life-saving interventions (it did not for me, but rather it gave me a physiologic response of anxiety). As one would expect, in 2003 Smith and Pell reported they found no RCT's in their systematic review to see if parachutes reduced the risk of death or serious injury (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/). However, there was an RCT published in 2015 showing that parachutes do not reduce the risk of death or major injury (https://www.bmj.com/content/363/bmj.k5094), but it can't be extrapolated to higher elevations. Most interestingly, in 2016 there was a self-published case study on jumping from 25,000' without a parachute or wingsuit which was successful (https://youtu.be/Xz2W_QC5vKs) but I don't think it would be ideal for a larger-scale study as most people would probably have the same response I did watching it.
David
Thanks David! Great additions to the thought experiment! The case series on YouTube is interesting as an example of alternative interventions. The intervention condition - parachutes - had 3 subjects. The control condition - a huge net - had one subject. In this case series everyone had an intervention and it was comparative. There’s certainly a need for studying alternatives. When studying alternatives the reasonableness of the alternative should rationally (not empirically) be considered and the probability of success should be weighed. Here even the empiricist Bradford Hill (of Hill’s Criteria of Causation) has a rational consideration - the plausibility of the causal factor. It is plausible that a net would be effective, assuming the person falling is capable to hitting the net. But I agree with you - not many people would find the net reasonable in terms of someone’s ability to hit the target! I guess an analogy could be drawn to a recent systematic review I read on the Nordic hamstring exercises to reduce the risk of hamstring injury in athletes (https://bjsm.bmj.com/content/49/6/349.short). Turns out the reduction in risk requires people actual do the exercises (hit the net so to speak). The papers you cite may be a bit more extreme attacks on EBP - but I admit to only having read the abstracts. I think using parachute interventions to try to argue against EBP for non parachute interventions is a slippery slope. I think when it comes to evidence for practice we need to be more agile than the current “pyramid” may allow - or perhaps I just see that the pyramid is interpreted too strictly by some people. This reminds me of how even the American Statistical Association wants to completely avoid use of the p-value and terminology related to its interpretation in hypothesis testing. This over reaction is not because the p-value doesn’t measure exactly what it is supposed to measure. It’s because people get overly rigorous about it. So avoid mis-use, we must stop using. Why either/or? Why not both/and? Why not a mix of rationalism and realism and pragmatism with empiricism regarding evidence?
The silo’s - yes, that’s a quandary. I had an adjunct faculty once tell our students just to “bear with it” while learning in courses that “would not be needed” when they were practicing where they wanted to practice (outpatient orthopedics). I was very dismayed and had to respond. Have you read: David Epstein: Range: Why Generalists Triumph in a Specialized World? https://davidepstein.com/the-range/
Thanks for reading and commenting!
Sean
Upon re-reading my post above, there’s one more point to make here. Even if an intervention that saves a life is only effective a small amount of the time (i.e. CPR or defibrillation), since non intervention is clearly less effective then a small efficacy, it is still, relatively, largely effective. In other words, if my heart stops beating please do CPR even though the odds are low, because the odds of not doing it are lower.