The agnostic approach to effectiveness

To the agnostic, real world experience reins supreme when it comes to evaluating effectiveness. The Randomized Controlled Trial (RCT) results are only relevant to the extent they demonstrate that both success and failure are indeed possible when using a new therapy. However, the numerical (efficacy) estimates are not relevant for the agnostic and should be discounted when real world effectiveness is to be assessed. The latter can only be ascertained by looking at the outcomes of actual patients so in order to acknowledge the RCT results, they too need to be cast in this format. The extreme agnostic attitude would do so in a manner that minimizes to the greatest possible extent the impact of the reported RCT efficacy on inferences, e.g. by appraising it as worthy of one success and one failure in real world patients. These “pseudocases” are added to the corresponding numbers obtained in the real world and the agnostic proceeds to apply Bayes theorem. Mathematically the agnostic assumes a prior in which the prior probability of success can be any number between 0  and 1 (the Laplace prior) to represent the two extreme viewpoints of the therapy, i.e. it is either rat poisson or holy water.
The agnostic attitude will not mislead the clinician, even for small number of real world cases:
but it will severly impair the clinician’s ability to make precise statements:
until the time that an extremely large body of evidence has been analyzed:
Hence, the agnostic does pay a premium by not fully acknowledging the trial results. This premium, which can be described as being too uncertain about one’s uncertainty may even have practical implications e.g. if a patient decides against the new therapy because of the clinician’s uncertainty regarding the therapy of evidence. It is important thus for the skeptic to keep in mind that lack of evidence is not evidence of lack!

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