Advancing the evidence-based healthcare debate

Reasoning, evidence, and clinical decision-making: The great debate moves forward

When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life.

Progress in evidence-based medicine: a quarter century on

In response to limitations in the understanding and use of published evidence, evidence-based medicine (EBM) began as a movement in the early 1990s. EBM's initial focus was on educating clinicians in the understanding and use of published literature to optimise clinical care, including the science of systematic reviews. EBM progressed to recognise limitations of evidence alone, and has increasingly stressed the need to combine critical appraisal of the evidence with patient's values and preferences through shared decision making. In another progress, EBM incorporated and further developed the science of producing trustworthy clinical practice guidelines pioneered by investigators in the 1980s. EBM's enduring contributions to clinical medicine include placing the practice of medicine on a solid scientific basis, the development of more sophisticated hierarchies of evidence, the recognition of the crucial role of patient values and preferences in clinical decision making, and the development of the methodology for generating trustworthy recommendations.

Evidence-based medicine use in pharmacy practice: a cross-sectional survey

RATIONALE, AIMS AND OBJECTIVES

This study aimed to evaluate the awareness, attitude, knowledge and use of evidence-based medicine (EBM) among pharmacists in Jordan.

METHODS

A cross-sectional self-reported survey was conducted on 122 pharmacists (both hospital and community) who were asked to fill a validated structured questionnaire.

RESULTS

The participants showed a positive attitude towards EBM; more than 80% thought that EBM improves patient care, improves quick knowledge update, helps to unify the quality of care provided, is a good educational tool and a convenient source of advice. But despite this positive attitude, pharmacists showed partial understanding of the technical terms used in EBM; also they relied on their own judgment, medical representatives and standard textbooks in making their decision, resources that can no longer be considered sufficiently updated and/or evidence based. Patient overload, lack of personal time and limited access to EBM sources were the most commonly identified barrier to practicing EBM. Also this study suggest that pharmacist's experience is negatively associated with EBM knowledge score (Spearman's rho value -0.187, P-value 0.04).

CONCLUSIONS

In spite of the positive attitude towards EBM, this study showed numerous personal and institutional barriers towards implementing EBM in Jordan, which necessitate immediate action by all health care decision makers to formulate a national plan to overcome such barriers, and to further investigate the evidence that teaching, learning and daily application of EBM in practice can improve the quality of care and reduce the cost.

Narrative reviews

Although qualitative researches (QR) are invaluable in understanding complex healthcare situations, the quantitative systematic reviews could not treat them. To improve quality of healthcare services, results of QR should be considered in healthcare decision-making processes. Several methods and theories for synthesizing evidences of QR have been developed. In order to activate the narrative reviews and mixed methods reviews in Korean healthcare academies, I arranged the related nomenclatures and suggested some issues to conduct them.

Reductionist inference-based medicine, i.e. EBM

RATIONALE, AIMS AND OBJECTIVES

Unbeknown to many, reductionist and postmodern worldviews competitively coexist in science and society. The debate on evidence-based medicine (EBM) is at the tip of this 'iceberg'. Via systems thinking and complexity science EBM reveals crucial flaws and its reductionism entails an inability to appreciate (even tolerate) contrasting ideas and/or 'see a bigger picture'. An interdisciplinary approach provides insight into novel explanations. Thereafter, the conceptual barrier shifts to communication, a challenge which mandates attempts to steer the discourse by reframing the debate.

METHOD

Interdisciplinary perspectives serve to illustrate a 'bigger picture'. Also, 'wicked' questions stimulate reflection, discern leverage points and dismantle resilient defences. Lastly, a proposal: exploring the value of 'glasses half full'.

CONCLUSION

Some may realize that postmodern concepts behind compelling criticisms to EBM have already taken root, being shared by policymakers, practitioners and patients as well.

Beyond 'faith-based medicine' and EBM

RATIONALE, AIMS AND OBJECTIVES

Longstanding debate on evidence-based medicine (EBM) may have reached a critical saturation point. I briefly report on systematic reviews on the recurring themes in the critical literature. In this context, some criticisms to EBM are substantial and enduring, although convincing arguments to contrast unresolved issues have yet to be produced. Nonetheless, few changes have been adopted and conservative attitudes persist in EBM. Despite its 'success', implementation in practice has been inexorably overshadowed leading to paradoxical shortcomings. This controversial scenario offers a formidable occasion to gain needed insight. The aim of this paper is to attempt a comprehensive analysis by reframing a number of key concerns, while furnishing pragmatic, interdisciplinary solutions for these deep-rooted dilemmas. In the interests of all stakeholders, I seek to promote a concerted effort to resolve conflict and build consensus.

METHODS

This paper explores a strategically unifying vision of primary care, based on current understanding of practice patterns, having a research-friendly 'common ground' where practitioners' information needs may be met. In addition, an analysis of existing problems identifies underlying 'root causes'. Moreover, I expediently reframe crucial matters by focusing on EBM, more than as a paradigm, as an organisation, hence amenable to a variety of cross-disciplinary analyses and solutions. Finally, recent state-of-the-art reviews on implementation and dissemination research are cited for the pertinent implications for study design and practice.

RESULTS

Present policies and influential testimonials on behalf of EBM encounter the pitfalls of hindering learning and progress through defensive attitudes and mechanisms. Current study designs and evaluation criteria must strive to adapt to real-world settings, rather than vice versa.

CONCLUSIONS

The arguments exposed herein alter the terms of the debate on EBM and may outline a basis for initiatives with conflict-resolution and consensus-building scopes.

Evidence-based psychiatry: understanding the limitations of a method

Evidence-based psychiatry (EBP) is an important and useful method. However, it covers only a limited range of clinical problems psychiatrists and psychotherapists encounter in daily work. This is due to some particularities of psychiatric diagnoses and therapeutic practice. (i) The validity of psychiatric diagnoses is limited. EBP is entirely depending on diagnoses, so one of its core assumptions is of doubtful applicability in the field of psychiatry and psychotherapy. (ii) Effects of complexity are more obvious in psychiatric and psychotherapeutic cases. Owing to its conceptual bases, EBP cannot sufficiently consider such effects and is therefore of limited usefulness addressing particular problems in fluctuating or symptomatically shifting diseases. (iii) EBP's strong focusing on decision making does not reflect appropriately the clinical reality of psychiatrists and psychotherapists. Diagnostic and therapeutic procedures are in fact more iterative, and decisions are constantly re-evaluated. EBP is not helpful to adjust this type of individual approach, which is needed to treat individual patients.

Implications of Cyberspace Communication: A Role for Physicians

Through the presentation of three clinical case reports and subsequent discussion, it is demonstrated that physicians must begin to familiarize themselves with the health-related implications of online communication, and must proactively address Internet use as it relates to health and well-being. Included case presentations highlight the following: the established association between those seeking sexual partners through the Internet and an increased risk for sexually transmitted disease; the implications of cyber-communication for young people and concerns related to unsafe online behaviors including sharing identifying information with strangers; the potential use of strategically constructed virtual identities to facilitate sexual exploitation; the impact of accelerated intimacy and disinhibition evident in online communication; and the invasive nature of Internet sexual harassment or bullying. Although it is recognized that most online activities do not negatively affect health, doctors must be prepared to ask patients about Internet use and become involved in educating children, teenagers, and parents about safe online relationships to promote optimal physical, mental, and social health.

Evidence, Research, Knowledge: A Call for Conceptual Clarity

OBJECTIVE

To dispel some of the conceptual confusion in the field of evidence-based practice that has resulted from the overlapping use of the terms research, evidence, and knowledge.

APPROACH

Theoretical discussion.

FINDINGS

Often the terms research and knowledge are used as synonyms for evidence, but the overlap is never complete. The term evidence has long been understood to mean the findings of research.

DISCUSSION

Recent attempts to broaden the definition of evidence to include clinical experience and experiential knowledge have been misguided. Broadening our understanding of the basis for clinical decision making and conceptualizing evidence are quite different tasks. Other factors (not other forms of evidence) do shape the clinical decision-making process, but they are not evidence. We might better term them knowledge. Confusing evidence with these other factors has hindered research and the improvement of clinical decision making in health care. We argue that this confusion results from the use of the term evidence when we really mean either research findings or knowledge.

CONCLUSIONS

In this article, we have argued for specificity in the use of the term evidence. We urge the restriction of the term evidence to research findings, and while we acknowledge the importance of other influences on the clinical decision-making process, we insist that they are not evidence. The time has come to value personal experience and experiential knowledge for what they are-we should not have to disguise them as types of evidence for them to be deemed of any value. Being specific to language, the goal is to improve clinical decision making by increasing practitioners' reliance on research findings (evidence) while acknowledging (and valuing) the important part played by other forms of knowledge in the decision-making process. The distinctions are important.

Evidence-based medicine in primary care: qualitative study of family physicians

BACKGROUND

The objectives of this study were: a) to examine physician attitudes to and experience of the practice of evidence-based medicine (EBM) in primary care; b) to investigate the influence of patient preferences on clinical decision-making; and c) to explore the role of intuition in family practice.

METHOD

Qualitative analysis of semi-structured interviews of 15 family physicians purposively selected from respondents to a national survey on EBM mailed to a random sample of Canadian family physicians.

RESULTS

Participants mainly welcomed the promotion of EBM in the primary care setting. A significant number of barriers and limitations to the implementation of EBM were identified. EBM is perceived by some physicians as a devaluation of the 'art of medicine' and a threat to their professional/clinical autonomy. Issues regarding the trustworthiness and credibility of evidence were of great concern, especially with respect to the influence of the pharmaceutical industry. Attempts to become more evidence-based often result in the experience of conflicts. Patient factors exert a powerful influence on clinical decision-making and can serve as trumps to research evidence. A widespread belief that intuition plays a vital role in primary care reinforced views that research evidence must be considered alongside other factors such as patient preferences and the clinical judgement and experience of the physician.

DISCUSSION

Primary care physicians are increasingly keen to consider research evidence in clinical decision-making, but there are significant concerns about the current model of EBM. Our findings support the proposed revisions to EBM wherein greater emphasis is placed on clinical expertise and patient preferences, both of which remain powerful influences on physician behaviour.

Seeking evidence from medical research consumers as part of the medical research process could improve the uptake of research evidence

Concerns have been expressed about gaps between available medical research evidence and current medical practice. These gaps have been attributed to process problems with the implementation of evidence previously judged to be appropriate, rather than to problems with the appropriateness of the evidence provided for implementation. Two such 'appropriateness' problems are the applicability of research evidence to an individual patient, and the acceptability to an individual patient of a proposed treatment. Part of both these problems is due to the pre-eminence of the scientific paradigm within the medical research domain, and of the randomized controlled clinical trial within that domain. However, there is an opportunity beneficially to address both these problems by supporting reciprocal communication between medical research 'producers' and medical research 'consumers'--both practising clinicians and patients' representatives--in the setting of research priorities, selection of topics for research, development of research questions and study designs, in-progress reviewing, and final reporting of medical research projects. Such communication could allow researchers to understand, and respond to, clinicians' and patients' inputs concerning the applicability, utility and acceptability issues that will ultimately affect whether, and how, medical research findings can be applied. Such communication could also assist with some post-research implementation issues: integration of appropriate evidence into everyday practice; access to appropriate information sources; and a critical lack of necessary time.

Non-linearity in clinical practice

The whole spectrum of medicine consists of complex non-linear systems that are balanced and interact with each other. How non-linearity confers stability on a system and explains variation and uncertainty in clinical medicine is discussed. A major theme is that a small alteration in initial conditions may have a major effect on the end result. In the context of non-linearity, it is argued that 'evidence-based medicine' (EBM) as it exists today can only ever be relevant to a small fraction of the domain of medicine, that the 'art of medicine' consists of an intuitive 'tuning in' to these complex systems and as such is not so much an art as an expression of non-linear science. The main cause of iatrogenic disease is interpreted as a failure to understand the complexity of the systems being treated. Case study examples are given and analysed in non-linear terms. It is concluded that good medicine concerns individualized treatment of an individual patient whose body functions are governed by non-linear processes. EBM as it exists today paints with a broad and limited brush, but it does promise a fresh new direction. In this context, we need to expand the spectrum of scientific medicine to include non-linearity, and to look upon the 'art of medicine' as a historical (but unstated) legacy in this domain.

If not evidence, then what? Or does medicine really need a base?

This essay analyses the concept of ' base' in relation to its use in evidence-based medicine (EBM). It evaluates the extent to which evidence provides a sufficient base for health care to rest and discusses whether medicine needs a base, and, if so, what are the other possible candidates. This paper will argue that EBM is linked epistemologically to the theory of foundationalism and shows how important criticisms of EBM emerge from anti-foundationalist epistemologies and interpretive frameworks. Drawing from recent writings in the philosophy of science, it is argued that there is a need to see multiple perspectives relevant to the practice and understanding of medicine.

Reflexivity and metapositions: strategies for appraisal of clinical evidence

According to Sackett, evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. In this article, clinical reasoning is depicted as multilayered processes of evidence construction by means of social interaction and human interpretation. A basic set of knowledge is the doctors initial capital at the onset of the individual encounter. This is a necessary, but insufficient, presumption for the elaboration of clinical knowledge required to solve the particular problem. A diagnostic conclusion may appear to constitute the most obvious part of knowledge. Yet the formulation of hypotheses and the choice of adequate strategies for the pursuit of evidence are perhaps even more significant dimensions of clinical knowledge. Potential biases affect the ways in which evidence is gathered and used. When clinicians are not committed to appraising the evidence constituting the foundations of their enterprise, quality assessment of clinical practice becomes casual and unreliable. Reflexivity implies having a self-conscious account of the production of knowledge as it is being produced. From metapositions, critical questions can be asked and sometimes answered. Evidence-based practice in the original sense requires that doctors reflect upon their own positions as knowers, in the process of situated knowing, where certain rhetorical spaces rule.

Clinical governance: vision or mirage?

Clinical governance was intended to ensure clinical quality in the National Health Service. Its first full description, in the British Medical Journal in 1998, seemed to some to be more rhetoric than substance. Now, 3 years on, its proponents believe it is starting to achieve its purpose. The British Medical Journal has again published a paper, this time subtitled 'turning vision into reality'. Expectations might have been that this paper would present evidence of how clinical governance is changing practice to ensure quality, but analysis of the paper shows that it does little more than repeat the rhetoric of the earlier description. It describes how clinical governance might be organized and what it might do, but not what it has done. Its authors repeat the idea that everyone can be 'the best' and achieve 'exellence', which is not reality at all. Anyone introducing a new method of managing the National Health System has the same obligation as those who introduce new treatments to provide evidence that the method works, and that the financial and non-financial costs are not too high. The new paper fails to provide that evidence.

Clinical evaluation: constructing a new model for post-normal medicine

The current paradigm in medicine is served by an explanatory model based on scientific positivism. We argue that there are inherent weaknesses in this model: its basis on reductionism, its reliance on linear thinking and its failure to incorporate human values invite a revision of our thinking about knowledge in medicine. We propose that a fresh explanatory model should be based on complexity theory, and argue that this better suits the new era of post-normal medicine, where analytical and predictive power are obtained by stepping back and looking at the relationships and overall context of a system rather than forcing reality into a preferred disciplinary framework. Better at times to be vaguely right, we argue, rather than precisely wrong.

Including qualitative research in systematic reviews: opportunities and problems

Qualitative research has been increasingly recognized in recent years as having a distinctive and important contribution to make to health care research. It is capable of being used as a methodologically sufficient approach in its own right, as a precursor to quantitative studies, during or after trials to explain processes and outcomes, and as a means of enhancing the link between evidence and practice. However, qualitative research has been little used as an evidence resource for systematic reviews. We argue that formal synthesis of both qualitative and quantitative forms of research is essential, and we discuss some of the problems that need to be overcome in carrying out such syntheses. These include methodological prejudice, problems in searching for qualitative evidence, and issues in synthesizing qualitative data. We call for progress to be made on the science and methods of including qualitative research in the evidence base of medicine.

Evidence-based medicine: the need for a new definition

Evidence is defined by its ability to establish or support conclusions. Evidence-based medicine (EBM) equates evidence with scientific evidence and views factors such as clinical expertise as important in moving from evidence to action. In contrast, we suggest that EBM should acknowledge multiple dimensions of evidence including scientific evidence, theoretic evidence, practical evidence, expert evidence, judicial evidence and ethics-based evidence. What EBM loses by not acknowledging these dimensions as evidence is the ability, among other things, to make and defend judgements based on understandings that complement science and are no less important than those science can offer. We argue for a new definition of EBM that, without forced accommodation or unacceptable compromise, acknowledges dimensions of evidence produced within and outside science.

Evidentiary challenges to evidence-based medicine

The evidence-based medicine (EBM) movement has exerted a strong influence on contemporary medicine. It has been used to define the hierarchy of knowledge in clinical medicine by classifying clinical findings according to the perceived relevance and validity of the respective methodologies of studies from which evidence was collected. In the spectrum of theories of knowledge, EBM predominantly relies on findings obtained from population-derived clinical research. This reliance on knowledge obtained from population studies sharply contrasts with a physiologic model of clinical knowledge advocated by basic science researchers and many clinicians. An apparent schism between proponents of physiologic and population models in the approach to the practice of medicine has been created. This dichotomy between practising physicians and EBM physicians in the approach to clinical knowledge should not be irreconcilable. We advocate a consilient approach to the interpretation of evidence and the integration of medical knowledge. This approach relies on 'linking of facts and fact-based theory across various disciplines to create a common groundwork of explanation'.