Kenneth M. Kessler, MD
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Kessler KM. Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding. Ann Intern Med. 2004;141:79. doi: 10.7326/0003-4819-141-1-200407060-00028
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Published: Ann Intern Med. 2004;141(1):79.
TO THE EDITOR:
The recent endoscopy guidelines from the Nonvariceal Upper GI Bleeding Consensus Conference Group (1) illustrate that a single hierarchy of evidence can lead to illogical conclusions. Because endoscopy is supported by level I evidence, it follows that all processes necessary to perform endoscopy equally supported. It is illogical to assign the availability of an endoscopist, support personnel, and the patient (recommendations 1, 2, and 3, respectively) to an inferior position because these recommendations are based on opinion. While opinion may represent the poorest level of experimental evidence, some opinions, for example, those not open to experimental verification or those representing axiomatic or self-evident truths, may be equally likely to be true as those problems that may be verified by empirical research. It is flawed logic to adopt a single hierarchy that would assign 1 + 1 = 2 to the lowest level of evidentiary import. Empirical truths are based on this mathematical definition of counting numbers and therefore cannot be stronger in truth value than the definition itself. Conversely, experimental data should not mask decisions based in part or in whole on opinion. It is illogical that the experts unanimously agreed that endoscopy for rebleeding (recommendation 13) was an “A” recommendation supported by level I evidence on the basis of a single controlled yet nonrepresentative study. One can only infer that the recommendation was based on lesser degrees of evidence or opinion and that reasoning was obscured by the greater evidentiary import of a single flawed study. While evidence-based medicine serves the science of medicine, medicine as a whole exists in a world of other truths, including those that are moral, legal, and physical, that challenges the advisability of adopting a single experimentally based hierarchy system to reflect the relative value of all truths.
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