A critical appraisal of evidence-based medicine: some ethical considerations

The Successful Return-To-Work Questionnaire for Cancer Survivors (I-RTW_CS): Development, Validity and Reproducibility

Background

Cancer survivors’ perspectives on a successful return to work (RTW) may not be captured in the common measure of RTW, namely time until RTW.

Objective

The purpose of this study was therefore to develop an RTW outcome measure that reflects employed cancer survivors’ perspectives, with items that could be influenced by an employer, i.e. the Successful Return-To-Work questionnaire for Cancer Survivors (I-RTW_CS), and to assess its construct validity and reproducibility.

Methods

First, three focus groups with cancer survivors (n = 14) were organized to generate issues that may constitute successful RTW. Second, a two-round Delphi study among 108 cancer survivors was conducted to select the most important issues. Construct validity of the I-RTW_CS was assessed using correlations with a single-item measure of successful RTW and the Quality of Working Life Questionnaire for Cancer Survivors (QWLQ-CS; n = 57). Reproducibility (test–retest reliability) was assessed using the intraclass correlation coefficient (ICC; n = 50).

Results

Forty-eight issues were generated, of which seven were included: ‘enjoyment in work’; ‘work without affecting health’; ‘confidence of employer without assumptions about work ability’; ‘open communication with employer’; ‘feeling welcome at work’; ‘good work–life balance’; and ‘joint satisfaction with the situation (employer and cancer survivor)’. Correlations with single-item successful RTW and QWLQ-CS were 0.58 and 0.85, respectively. The reproducibility showed an ICC of 0.72.

Conclusions

The I-RTW_CS provides an RTW outcome measure that includes cancer survivors’ perspectives and weights its items on an individual basis, allowing a more meaningful evaluation of cancer survivors’ RTW. This study provides preliminary evidence for its construct validity and reproducibility.

"Best interest" and Pediatric End Stage Kidney Disease: The Case of Baby M

In everyday clinical practice, health professionals and parents of chronically ill children often rely on the principle of 'best interest' in the development of medically oriented treatment plans. In most cases, such processes are done collaboratively; however, 'best interest' as a standard for decision-making becomes ambiguous in situations wherein parents and health professionals fail to agree on the course of treatment. This paper will explore the potential tensions that can exist in clinical practice when 'best interest' is used for making health care decisions. The discussion will be framed within the case of baby M, a newborn child of Mennonite descent diagnosed at birth with end-stage kidney disease (ESKD). M's parents refused medically-prescribed therapy on behalf of their child because of the uncertainty of the treatment and beliefs regarding quality of life. This case highlights that the application of the 'best interest' principle in the clinical domain can be ambiguously interpreted and subjectively operationalized along a narrowly defined medical understanding of what is in the patient's best interest. In addition, this case serves as an example of how power within the health care system can be used to operationalize a medically-sanctioned definition of 'best interest', often at the expense of the values, beliefs and interests of parental caregivers.

Clinically, what ought we to believe?

OBJECTIVE:

To question the status of the randomised controlled trial (RCT) in the hierarchy of evidence.

CONCLUSIONS:

The RCT provides important and clinically relevant information, particularly in psychopharmacology. However, and as with other methodologies, RCTs too are flawed and automatic abdication to their conclusions, especially in complex social interventions, is unwise. A clinical example with conflicting and polarising views, each with their evidence base, is described alongside a suggested clinical strategy for resolving differences of opinion.

Colliding discourses

The aim of this paper is to bring to the surface issues of power and authority in the process of seeking ethical approval for health service research in the UK in relation to the dominant discourse about methods to generate data and results that constitute legitimate ‘evidence’. In order to demonstrate how alternative and competing discourses may be silenced, I offer a deconstructive readings of the term ‘evidence’ as applied to healthcare, and excerpts of policy documents, which provide the framework for the ethical review of research proposals. I debate how the discourse shaped my own experience of seeking ethical approval for a participatory evaluation project involving Consultant Nurses. Furthermore, I engage in a dialogue with other texts in the literature in order to open up possible patterns and to generate alternative explanations and discourses which seek to promote constructive dialogue rather than regulation.

Trends in nursing ethics research: Mapping the literature production

BACKGROUND

There have been a number of debates in the field of nursing ethics. Researchers have focused on various aspects of nursing ethics, such as professional ethics, professional, nursing and ethical values. Within this research, a variety of literature reviews have been conducted, but to the best of our knowledge, bibliometric mapping has not yet been used.

OBJECTIVE

This article aims to analyse the production of literature within nursing ethics research.

RESEARCH DESIGN

In order to examine publishing patterns, we focused on publishing dynamics, prolific research entities and the most-cited articles. We additionally visualised the content of the literature using a novel mixed-method approach, combining bibliometric analysis and mapping with thematic analysis. Ethical considerations: In our study, ethical review was not required.

FINDINGS

A total of 1416 information sources were found in the Scopus database. Overall, literature production has increased; however, in recent years, the quantity of published material has begun to decrease. The most prolific countries are the United States, the United Kingdom and Canada, and the most prolific source titles are Nursing Ethics, Journal of Advanced Nursing and Nursing Times. Lately, research in the field of nursing ethics has been focused more on life care (providing for the basic needs of older residents), moral distress and community nursing.

DISCUSSION

The dynamics of research literature production showed an exponential rise in the number of published information sources - a rise which started in the period between 1974 and 1998. Since that period, the trend has stabilised, which might indicate that nursing ethics research is starting a transition to a mature phase.

CONCLUSION

The innovative use of bibliometric analysis and mapping, together with thematic analysis, is a useful tool for analysis of research production in the field of nursing ethics. The results presented can be an excellent starting point for literature reviews and more exhaustive data, information and knowledge seeking.

Ethics Issues Arising in the Transition to Learning Health Care Systems: Results from Interviews with Leaders from 25 Health Systems

INTRODUCTION

There is increased interest in transitioning to a "learning health care system" (LHCS). While this transition brings the potential for significant benefits, it also presents several ethical considerations. Identifying the ethical issues faced by institutions in this transition is critical for realizing the goals of learning health care so that these issues can be anticipated and, where possible, resolved.

METHODS

29 semi-structured telephone interviews were conducted with leaders within 25 health care institutions. Respondents were recruiting using purposive sampling, targeting institutions considered as LHCS leaders. All interviews were audiorecorded and transcribed. NVIVO10 software was used to support qualitative analysis.

RESULTS

Respondents described seven ethical challenges: (1) ethical oversight of learning activities; (2) transparency of learning activities to patients; (3) potential tensions between improving quality and reducing costs; (4) data sharing and data management; (5) lag time between discovery and implementation; (6) transparency to patients about quality; and (7) randomization for quality improvement initiatives.

DISCUSSION

To move towards LHCS, several ethical considerations require further attention, including: the continued appropriateness of the research-treatment distinction; policy frameworks for privacy and data sharing; informing patients about learning activities; obligations to share data on quality; and the potential for trade-offs between quality improvement and cost control.

CONCLUSION

To our knowledge, this is the first project to ask leaders from health care systems committed to ongoing learning about the ethical issues they have faced in this effort. Their experiences can provide guidance on relevant ethical issues, and what might be done to resolve them.

Evidence-informed person-centred health care (part II): are 'cognitive biases plus' underlying the EBM paradigm responsible for undermining the quality of evidence?

INTRODUCTION

Recently, some leaders of the evidence-based medicine (EBM) movement drew attention to the "unintended" negative consequences associated with EBM. The term 'cognitive biases plus' was introduced in part I to encompass cognitive biases, conflicts of interests, fallacies and certain behaviours.

HYPOTHESIS

'Cognitive biases plus' in those closely involved in creating and promoting the EBM paradigm are responsible for their (1) inability to anticipate and then recognize flaws in the tenets of EBM; (2) discounting alternative views; and (3) delaying reform.

METHODS

A narrative review style was used, with methods as in part I.

APPRAISAL OF LITERATURE

Over the past two decades there has been mounting qualitative and quantitative methodological evidence to suggest that the faith placed in (1) the EBM hierarchy with randomized controlled trials and systematic reviews at the summit; (2) the reliability of biostatistical methods to quantitate data; and (3) the primacy of sources of pre-appraised evidence, is seriously misplaced. Consequently, the evidence that informs person-centred care is compromised.

DISCUSSION

Arguments focusing on 'cognitive biases plus' are offered to support our hypothesis. To the best of our knowledge, EBM proponents have not provided an explanation.

CONCLUSIONS

Reform is urgently needed to minimize continuing risks to patients. If our hypothesis is correct, then in addition to the suggestions made in part I, deficiencies in the paradigm must be corrected. Meaningful solutions are only possible if the biases of scientific inbreeding and groupthink are minimized by collaboration between EBM leaders and those who have been sounding warning bells.

The Limits of Evidence-Based Medicine and Its Application to Mental Health Evidence-Based Practice: Part One

The present article outlines the major limitations of evidence-based medicine (EBM) and through a close review demonstrates that the three component EBM process model is a pseudoscientific tool. Its “objective” component is the collection, systematic analysis, and listing of “effective” treatments applying a research hierarchy from most rigorous (systematic reviews of randomized controlled trials [RCTs]) to least rigorous (expert opinion). Its two subjective components are the clinical judgment of helping professionals about which “evidence-based” treatment to select and the specific and unique relevant personal preferences of the potential recipients regarding treatment. This procedural mishmash provides no more rigor in choosing “best practice” than has been provided by good clinical practitioners in the past because both turn out to be subjective and authority based. The article also discusses EBM’s further methodological dilution in the National Institute of Mental Health (NIMH) endorsed Evidence-Based Mental Health Practice (EBP) movement. In EBP, the allegedly rigorous EBM protocol is altered. Instead of systematic expert protocol-driven EBM reviews of RCTs, NIMH sanctioned expert consensus panels decide “evidence-based practices.” This further problematizes the development of best practices in mental health by converting it to a political process. The article concludes with some observations on these issues. In a second article (part two) forthcoming, assertive community treatment (ACT) is examined as an example of an EBP that fails as a scientifically effective treatment despite its EBP certification and general popularity among practitioners.

The application of Cartwright's concept of capacities to complex interventions in psychiatry

Cartwright and Munro argued that extrapolation of findings from randomized controlled trials to other settings can be difficult because information about the underlying causal structure and subgroups is often not available. They advocated the use of 'capacities' - that is fixed causal contributions - in predicting effects of interventions. In psychiatry, it is often not possible to determine what the fixed causal contributions are and one can only establish 'approximate capacities'. However, using 'approximate capacities' does imply a different way of evaluating health services, especially combined interventions. In health service research, if different studies, randomized controlled trials or other designs, have given different outcomes, the best way to investigate the effectiveness of a particular way of service organization is not to conduct more randomized controlled trials. It is preferable to study the effects of certain elements of the complex intervention, which have been tested before in other settings, that is investigating 'approximate capacities'. One should check whether the separate elements do form a part of the complex intervention in practice and whether they have the same effect as in other studies and if not, why not. This enhances knowledge about the underlying causal structure and increases the possibility of extrapolation of the findings.

Towards a new definition of return-to-work outcomes in common mental disorders from a multi-stakeholder perspective

Objectives

To examine the perspectives of key stakeholders involved in the return-to-work (RTW) process regarding the definition of successful RTW outcome after sickness absence related to common mental disorders (CMD’s).

Methods

A mixed-method design was used: First, we used qualitative methods (focus groups, interviews) to identify a broad range of criteria important for the definition of successful RTW (N = 57). Criteria were grouped into content-related clusters. Second, we used a quantitative approach (online questionnaire) to identify, among a larger stakeholder sample (N = 178), the clusters and criteria most important for successful RTW.

Results

A total of 11 clusters, consisting of 52 unique criteria, were identified. In defining successful RTW, supervisors and occupational physicians regarded “Sustainability” and “At-work functioning” most important, while employees regarded “Sustainability,” “Job satisfaction,” “Work-home balance,” and “Mental Functioning” most important. Despite agreement on the importance of certain criteria, considerable differences among stakeholders were observed.

Conclusions

Key stakeholders vary in the aspects and criteria they regard as important when defining successful RTW after CMD-related sickness absence. Current definitions of RTW outcomes used in scientific research may not accurately reflect these key stakeholder perspectives. Future studies should be more aware of the perspective from which they aim to evaluate the effectiveness of a RTW intervention, and define their RTW outcomes accordingly.

Improved health or improved decision making? The ethical goals of EBM

Evidence-based medicine (EBM) is frequently portrayed as a value-free approach to knowing what kinds of treatment 'really work.' Since practitioners should help patients to improve their health, and EBM tells us which interventions will work, then it follows that we must practice EBM, offering only those interventions supported by evidence. The primary goal of EBM, then, is an ethical one - to improve health. More recently, EBM's authors have also committed themselves to 'shared decision making' in which evidence plays a role in the clinical encounter, but where patients, motivated by their own values, should have final decision-making authority. Envisioned this way, strengthening the informed consent process, rather than improved health per se, is viewed as the goal of EBM. In this paper, I will explore this shift in EBM's ethics from the goal of improved health towards the goal of strengthened informed consent. Drawing upon data from a qualitative enquiry of scholars involved in the development of EBM, I will argue that EBM is now committed to both of these ethical goals. Where they conflict, the aim of the intervention will determine which goal practitioners should pursue. Having increased the ethical complexity of EBM, we are left with the question of whether EBM would still be judged a success if it did not lead to much in the way of improvements in health, but primarily strengthened informed consent. This paper will conclude by arguing that this more nuanced version of EBM's ethics accurately reflects the dynamics of real clinical practice but undermines the original, perceived need for EBM.

Evidence-based medicine: revisiting the pyramid of priorities

Evidence-based medicine (EBM) is beset with numerous problems. In addition to the fact that varied audiences have each customarily sought differing types of evidence, EBM traditionally incorporated a hierarchy of clinical research designs, placing systematic reviews and meta-analyses at the pinnacle. Yet the canonical pyramid of EBM excludes numerous sources of research information, such as basic research, epidemiology, and health services research. Models of EBM commonly used by third party payers have ignored clinical judgment and patient values and expectations, which together form a tripartite and more realistic guideline to effective clinical care. Added to this is the problem in which enhanced placebo treatments in experimentation may obscure verum effects seen commonly in practice. Compounding the issue is that poor systematic reviews which comprise a significant portion of EBM are prone to subjective bias in their inclusion criteria and methodological scoring, shown to skew outcomes. Finally, the blinding concept of randomized controlled trials is particularly problematic in applications of physical medicine. Examples from the research literature in physical medicine highlight conclusions which are open to debate. More progressive components of EBM are recommended, together with greater recognition of the varying audiences employing EBM.

Evidence-based medicine in practice

Evidence-based medicine (EBM) has emerged as a dominant paradigm in healthcare, strongly influencing clinical decision-making, access to and funding for interventions. However, EBM has a number of limitations, which appear to have been under-represented in the literature. We explore the development and shortcomings of EBM, and consider a complementary role for practice-based evidence in guiding clinical decision-making. EBM is a valuable and important part of the medical landscape. However, a range of significant limitations makes over-reliance on this paradigm problematic. Appropriate recognition of practice-based evidence helps to bridge the gap between evidence and clinical practices.

An "education for life" requirement to promote lifelong learning in an internal medicine residency program

BACKGROUND

Lifelong learning is an integral component of practice-based learning and improvement. Physicians need to be lifelong learners to provide timely, efficient, and state-of-the-art patient care in an environment where knowledge, technology, and social requirements are rapidly changing.

OBJECTIVES

To assess graduates' self-reported perception of the usefulness of a residency program requirement to submit a narrative report describing their planned educational modalities for their future continued medical learning ("Education for Life" requirement), and to compare the modalities residents intended to use with their reported educational activities.

MATERIALS AND METHODS

Data was compiled from the Education for Life reports submitted by internal medicine residents at the University of Tennessee College of Medicine Chattanooga from 1998 to 2000, and from a survey sent to the same 27 graduates 2 to 4 years later from 2000 to 2004.

RESULTS

Twenty-four surveys (89%) were returned. Of the responding graduates, 58% (14/24) found the Education for Life requirement useful for their future continued medical learning. Graduates intended to keep up with a mean of 3.4 educational modalities, and they reported keeping up with 4.2. In a multivariable analysis, the number of modalities graduates used was significantly associated with the number they had planned to use before graduation (P  =  .04) but not with their career choice of subspecialization.

CONCLUSION

The majority of residents found the Education for Life requirement useful for their future continued medical learning. Graduates, regardless of specialty, reported using more modalities for continuing their medical education than they thought they would as residents. Considering lifelong learning early in training and then requiring residents to identify ways to practice lifelong learning as a requirement for graduation may be dispositive.

Rationality versus reality: the challenges of evidence-based decision making for health policy makers

BACKGROUND

Current healthcare systems have extended the evidence-based medicine (EBM) approach to health policy and delivery decisions, such as access-to-care, healthcare funding and health program continuance, through attempts to integrate valid and reliable evidence into the decision making process. These policy decisions have major impacts on society and have high personal and financial costs associated with those decisions. Decision models such as these function under a shared assumption of rational choice and utility maximization in the decision-making process.

DISCUSSION

We contend that health policy decision makers are generally unable to attain the basic goals of evidence-based decision making (EBDM) and evidence-based policy making (EBPM) because humans make decisions with their naturally limited, faulty, and biased decision-making processes. A cognitive information processing framework is presented to support this argument, and subtle cognitive processing mechanisms are introduced to support the focal thesis: health policy makers' decisions are influenced by the subjective manner in which they individually process decision-relevant information rather than on the objective merits of the evidence alone. As such, subsequent health policy decisions do not necessarily achieve the goals of evidence-based policy making, such as maximizing health outcomes for society based on valid and reliable research evidence.

SUMMARY

In this era of increasing adoption of evidence-based healthcare models, the rational choice, utility maximizing assumptions in EBDM and EBPM, must be critically evaluated to ensure effective and high-quality health policy decisions. The cognitive information processing framework presented here will aid health policy decision makers by identifying how their decisions might be subtly influenced by non-rational factors. In this paper, we identify some of the biases and potential intervention points and provide some initial suggestions about how the EBDM/EBPM process can be improved.

Ethics and EBM: acknowledging bias, accepting difference and embracing politics

Evidence-based medicine (EBM) has been effective because it confers both epistemic and moral authority, promising that both individual patient care and public health interventions are effective, safe and efficient, that these decisions and standards can be determined (and therefore judged) in a transparent manner and that this form of decision making is reliable, objective and value-free. The problem is that EBM refers to particular, ideologically and philosophically specific concepts of evidence, medicine and the relationship between them. The analysis of the 'ethics' of EBM, therefore, requires not only a critique of its philosophical naïvety and its attachment to modernism and positivism, but a critique of its social, cultural and political implications.

Balancing health care evidence and art to meet clinical needs: policymakers' perspectives

Rationale, aims and objectives Although many believe that evidence-based practice (EBP) has great potential, critics have identified limitations including a focus on randomized clinical trial (RCT) evidence to the exclusion of other evidence types and a disregard for the art of medicine. Others have argued, however, that proper application of EBP involves reasoned consideration of a wide variety of information; thus, the dichotomy between medical science and art may be false. We explore the views of executive-level policymakers from the Veterans Health Administration, a leader in the EBP movement, regarding what constitutes evidence and the relative importance of evidence versus practical needs when determining clinical policy. Method We conducted 26 semi-structured qualitative interviews and performed a content analysis. Results Although informants generally believed in the value of EBP and the role of RCTs within it, they also valued other types of evidence. Further, they had concerns that were sometimes antithetical with strict adherence to an evidence-based approach. These included practical concerns, fit with organizational values and with local circumstances, resources, political pressures and patient needs. They were especially concerned about how to address medical conditions that affect many individuals or high-risk populations that have no evidence-based treatment. Conclusion When possible, health care practice should be evidence-based. When this is not possible, health care providers must turn to the art of medicine by using consensus-based best practices. Further, it is important for policymakers and researchers to work in concert to develop EBPs that are practical and meet needs.

Perceptions, attitudes and knowledge of evidence-based medicine in primary care in Spain: a study protocol

BACKGROUND

The philosophy of evidence-based medicine (EBM) was introduced in the early 90s as a new approach to the practice of medicine, using the best available evidence to make decisions about health care. Despite ongoing controversy, EBM has developed enormously and physicians' attitude towards it is generally positive. Nevertheless, in Spain little is known about this topic. We will therefore undertake a study to explore perceptions, attitudes and knowledge about EBM among primary care physicians.

METHODS AND DESIGN

A mixed-method study combining qualitative and quantitative designs will target family practitioners in Spain with the objective of evaluating current attitudes and perceptions about evidence-based medicine. The project will consist of two phases: a first phase running focus groups to identify perceptions and attitudes of participants, and a second phase assessing their attitudes and knowledge about EBM by means of a survey. Both phases will explore these issues in three different subgroups: family practitioners, with or without previous formal education in EBM; members of working groups that formulate healthcare recommendations; and physicians in charge of training family practice residents. Additionally, we will undertake a systematic review to identify and synthesize the available evidence on this topic.

DISCUSSION

The study will identify and gain insight into the perceived problems and barriers to the practice of evidence-based medicine among general practitioners in Spain. The project will also evaluate the main knowledge gaps and training needs, and explore how evidence-based medicine is being taught to family medicine residents, the medical practitioners of the future. Our results will aid researchers and health care planners in developing strategies to improve the practice of evidence-based medicine in our country.

Levels of consciousness and awareness about evidence-based medicine among consultants in tertiary health care institutions in Nigeria

AIMS AND OBJECTIVES

Evidence-based medicine (EBM) incorporates results of health care research when making decisions about the clinical care of individuals. Information and communication technologies now play significant roles in organizing available research results in EBM software suites. This study examines the level of consciousness and awareness about EBM of consultants in tertiary health institutions in Nigeria.

METHODS

A total of 100 consultants were randomly selected from 10 of the 29 teaching hospitals in Nigeria and data were collected using a questionnaire and an interview schedule. From this data, 64 EBM awareness and utilization variables were identified and data on the dynamics of their inter-relationships were reported by 89 of the participants.

RESULTS

Of the 89 respondents, less than half (47.19%) have knowledge about EBM that could be considered as high, while EBM knowledge is low for the remaining respondents (52.81%). Evidence Summaries appear to be a more popular tool among the respondents than the resources of Journals and Clinical Guidelines.

CONCLUSIONS

Consultants in the teaching hospitals appeared not to have the high level of EBM consciousness and awareness that would be expected of them, although there is a consciousness that EBM will foster ease of access and promote equity in health care services.

Limitations of evidence in the practice of evidence-based medicine

The goal of evidence-based medicine (EBM) is to support population-based policies and individual medical decisions that serve to improve health outcomes through the use of the most proven effective treatments. The essence of EBM is to use evidence (typically research data) related to the effectiveness of medical interventions to guide decisions about whether to use those interventions in clinical practice. The quality of evidence is the critical component in understanding and using EBM. This article discusses the kinds and limitations of the evidence used in the practice of EBM.

Should research ethics triumph over clinical ethics?

Evidence-based medicine (EBM) and its main strategy, randomized clinical trials, have had less impact on medical practice than might be expected. Of the various reasons that make practitioners wary of applying research results, this paper explores some consequences of scientists' and research sponsors' adamant insistence that reliable science can only be achieved if protocols adhere exclusively to the ethics of investigation basically reduced to obtaining informed consent and avoiding risks as far as possible. This means, and has been explicitly contended, that neither patients nor doctors should fall prey to the therapeutic fallacy which leads them to expect that research will also take care of patient-subjects' medical welfare. Doctors would betray their profession if they allowed clinical research to disregard their therapeutic obligations in favour of strict scientific methodology, as is bound to happen when using placebos in spite of existing therapy, disregarding equipoise, disallowing benefit claims, emphasizing the distinction between research ethics and clinical ethics but denying any difference between therapeutic and non-therapeutic trials. That scientists and practitioners should not agree on needs and priorities in the medical context, constitutes an additional factor in the less than optimal reception of EBM by the health care professions.

Perceptions of evidence-based medicine: traditional acupuncturists in the UK and resistance to biomedical modes of evaluation

Acupuncture and other types of 'complementary and alternative medicine' (CAM) are proving increasingly popular in the UK. As attempts to incorporate acupuncture into allopathic medicine have grown in number, the issue of assessing its effectiveness in ways consistent with the concept of evidence-based medicine has become more urgent. The nature, relevance and applicability of such assessments remain controversial however. This paper reports a qualitative study of acupuncturists' own perceptions of evidence and evidence-based medicine in relation to their therapeutic interventions. The material is presented in two main sections: explaining how acupuncture works, and resisting evidence-based medicine. The interviews reveal a great deal of scepticism and ambivalence and a deep questioning of the salience of conventional (biomedical) modes of evaluation of interventions.

Viewpoint: Moving beyond evidence-based medicine

The evidence-based medicine movement has remained both well known and controversial since its inception. The authors reframe the evidence-based medicine debate by pointing out an underappreciated epistemological deficiency: evidence-based medicine as currently conceptualized cannot accommodate concepts that resist quantitative analysis and therefore cannot logically differentiate human beings from complex machines. The authors use Michael Polanyi's philosophy of tacit knowing (which refers to the taken-for-granted knowledge at the periphery of attention that allows persons to understand the world and discern meaning in it) as a starting point for rectifying this deficiency and for working towards an improved, person-centered epistemology of medical practice. The authors demonstrate that not only evidence-based medicine but also most traditional theories of medical practice need a concept such as tacit knowing to account for the kinds of knowledge human beings actually use. Polanyi's philosophy of tacit knowing is defined and briefly explained. A medical epistemology that can account for the tacit dimension of human knowledge and recognize physicians and patients as persons requires a revised conception of medical uncertainty and a recognition that clinician-patient interactions are central to medicine. The authors discuss practical implications of tacit knowing for medical practice, education, research, and health care policy and suggest ways for moving beyond evidence-based medicine towards a comprehensive epistemology of medical practice.

Knowledge and use of evidence-based practice of GPs and hospital doctors

RATIONALE, AIMS AND OBJECTIVES

Clinical effectiveness and evidence-based practice (EBP) are the cornerstone of modern day health care. Although many studies have explored attitudes and perceived knowledge of individual professions few have compared the factors between professional groups and in particular in the medical profession. We report a study comparing the views, knowledge and practice of hospital doctors with their general practitioner (GP) counterparts in terms of EBP and clinical effectiveness. In this way it was hoped to highlight not only any differences between these groups but also the needs of these groups and suggest some ways of fulfilling these.

METHODS

A postal questionnaire survey was completed by a random sample of 500 GPs and 500 hospital medics.

RESULTS

There was a significant difference between the groups with the GPs rating their skill level as lower that their medical doctor counterparts. Similarly, GPs reported using EBP steps less frequently than hospital doctors. Barriers to implementing EBP differed between the groups with GPs reporting difficulty with accessing a library and making time available.

CONCLUSION

A number of differences between GPs and their hospital counterparts were recorded which highlights the difference in educational and policy approach required for greater uptake of EBP.

Evidence-based medicine and its role in ethical decision-making

The recent emergence of evidence-based medicine (EBM) presents medical ethics with the challenge of analyzing what is the current best medical evidence in ethical decision making. This article concludes that the use of the best available, most recently published research findings is a primary moral obligation. However, this does not automatically mean that the use of these research findings will lead to better ethical decision making. Research data can be distorted by methodological failings in the design and reporting of experiments, or by technical and commercial bias. Moreover, the introduction of norms, values, principles and ethical theories can lead to other choices than those proposed by empirical research findings. Ethical decision making must be informed and legitimated by the best available medical research. Nevertheless, ethical decision making is still primarily a choice based on values and norms.

Evidence-based medicine in treatment and rehabilitation of spinal cord injured

The interest for evidence-based medicine (EBM) has grown, due to the enormous and exponentially increasing amount of medical literature published. EBM is 'the integration of best research evidence with clinical expertise and patient values'. The steps in the EBM process are (1) convert the need for information into a question; (2) find the best evidence; (3) critically evaluate the evidence; (4) integrate the critical appraisal with clinical expertise and the patient's unique biology, values, and circumstances; (5) evaluate the process and seek ways to improve effectiveness and efficiency. Both limitations related to the accumulation of evidence and the use and possible misuse of EBM in the health care are important to be aware of in the daily clinical environment. For use of EMB in treatment and rehabilitation of spinal cord injury MEDLINE is the most sensitive source for evidence due to its comprehensiveness and up to date maintenance, and the best pre-appraised evidence source is the Cochrane Library and Best Evidence. Clinical Practice Guidelines may provide a good summary of the actual evidence. In spite of limitations and dangers related to EMB, health care professionals generally agree that they should strive to incorporate evidence-based interventions into the multifaceted clinical decision-making process, including the individual patient values and circumstances.

Quality of care: the need for medical, contextual and policy evidence in primary care

The increasing availability of medical evidence in clinical practice was expected to improve the quality of care. However, this has not been realized. A possible explanation is that quality of care is a complex concept and needs a wider scope. Starting from the Donabedian triangle of structure, process and outcome, a framework for the analysis of quality of care is presented. The need for three types of evidence is identified and discussed: medical, contextual and policy evidence. Although the body of medical evidence is increasing, it has major flaws and gaps hampering its applicability in primary care. There is also a need to focus on the context of the medical encounter, which has been shown to influence outcome, but is still not well researched. Finally, evidence on costs, cost utility and equity needs to be considered. Taking these different aspects of evidence into account, an agenda for research in primary care is set. The analytical framework may provide new insights in the quest for improving quality of health care.

Evidence-based Medicine: Why do Opponents and Proponents use the same Arguments?

There is quite some ethical controversy on Evidence-based Medicine (EbM) with regard to issues of physician autonomy as well as its allocative implications. Yet, there are some shortcomings in the current debate. First of all, some of the arguments brought up against EbM are similarly defaults of "classical medicine" as well, for instance its negligence of social aspects of medicine. Second, it is often maintained that EbM is just a tool to attain cost containment. This argument is false in two regards for neither is there any idea of cutting costs in the roots of EbM nor does EbM once practiced necessarily lead to less costs as there can be underuse as well as overuse. Third, both opponents and proponents of EbM come up with the same arguments against each other. Both maintain that the other way of practicing medicine does not allow for physicians' autonomy and free judgment. Therefore, we are going to search for the different presuppositions on which these "reproaches" rely. In this way we can demonstrate that both opponents and proponents rely on different notions of autonomy and free judgment in their argument. Finally, we hope to show that some of the ethical criticism may be raised against classical medicine as well and that allocation in terms of costs is not primarily an aim of EbM.

Evidence-based practice as mental health policy: three controversies and a caveat

Evidence-based practice (EBP) is the subject of vigorous controversy in the field of mental health. In this paper I discuss three distinct but interrelated controversies: how inclusive the mental health evidence base should be; whether mental health practice is a variety of applied science; and when and how the effectiveness goal in mental health is defined. I provide examples of evidence-based policy in mental health. These controversies pertain as well to general medicine. To the extent that they remain unresolved, evidence-based policy making may lead to ineffective and limited care.

Reflections on Ethical Concerns Arising from the Incorporation of Results of Randomized Trials of Antineoplastic Therapy into Routine Clinical Practice

There has been little discussion in the medical literature regarding the process whereby physicians elect to accept or reject the incorporation of results of randomized trials into their routine clinical practice. This decision-making process has the potential to result in serious ethical dilemmas.

Using qualitative research

A renewed urgency has emerged in the qualitative health research community concerning the utility of qualitative research. This urgency is the result of several converging trends in health care research, including the elevation of practical over basic knowledge, proliferation of qualitative health research studies, and the rise of evidence-based practice as a paradigm and methodology for health care. Diverse conceptualizations of use and users exist, and these have different implications for understanding, demonstrating, and enhancing the utility of qualitative research findings. Issues affecting the utilization of these findings include the varied ways in which they are conceived, presented, synthesized, signified, and translated, and the complex repertoire of skills required to activate the knowledge transformation cycle in qualitative health research fully.

First episode psychosis: a novel methodology reveals higher than expected incidence; a reality-based population profile in Northumberland, UK

RATIONALE, AIMS AND OBJECTIVES

To document the natural history/clinical course of an unselected population presenting with first episode psychosis across a Mental Health Trust.

METHOD

An observational database was set up covering all patients over 15 years of age. Data were collected at presentation and annual follow-up intervals.

RESULTS

A total of 227 patients presented during the 3 years initial study period with a first episode psychosis. The commonest diagnoses were psychotic depression 19%, paranoid schizophrenia 11%, persistent delusional disorder 7% and bipolar affective disorder 7.5% giving an annual incidence of 30.36 per 100 000 population. At presentation, half had been admitted to hospital, nearly half of whom were detained under the Mental Health Act, and only a quarter were currently employed. Twenty-six per cent had an episode of deliberate self-harm and 14% had harmed others. A recurring pattern emerged of over half the patients being no longer in contact with mental health services 1 year after presentation. Data collection is ongoing.

CONCLUSIONS

Clinical and managerial cooperation achieved a practical framework for data collection. This approach in an unselected population of patients yielded new insights into the course of first episode psychosis. The higher incidence than expected from the literature has implications for local strategic planning and provides a framework for detailed evaluation of a complex patient group.

Comparison between the two systems to evaluate the appropriateness of endoscopy of the upper digestive tract

OBJECTIVES

The aim of this study was to compare the diagnostic performance of the two systems for the evaluation of the appropriateness of upper digestive endoscopy suggested by the American Society of Gastrointestinal Endoscopy (ASGE) and by the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE).

METHODS

Patients referred for the upper digestive endoscopy (EGD) to a University Outpatients Clinic of Northeastern Italy were consecutively included in this prospective observational study. Before the EGD, the endoscopist assigned the patients to one of the ASGE appropriateness classes; another endoscopist then identified the detailed clinical scenario for the patients, which corresponds to scenarios examined by EPAGE by using a nine-point scale: 1-3 inappropriate; 4-6 uncertain; and 7-9 appropriate. The relationship between the appropriateness of use and the presence of relevant endoscopic lesions (neoplasms, ulcers, esophagitis, erosive gastritis/duodenitis, stenosis, and varices) was assessed, calculating the sensitivity and the specificity for each of the ASGE criteria, and each of the EPAGE scores, and plotting them to form a receiver operating characteristic (ROC) curve. The area under the ROC curve (AUC) provides a summary measure of test performance, and can vary from a minimum of 0.5 to a maximum of 1.0. We compared the AUC of the ROC curve derived from the ASGE criteria against that derived from the EPAGE criteria.

RESULTS

A total of 2,300 consecutive patients were included in the study (42% men; mean age: 57.3; range: 12-99); comparison of appropriateness criteria according to the ASGE and EPAGE could be made for 2,000 patients. The AUC of the ROC curve derived from the ASGE criteria was 0.553 (95% CI: 0.527-0.579), significantly higher than the AUC of the ROC curve derived from the EPAGE score: 0.523 (95% CI: 0.497-0.549; p < 0.05).

CONCLUSIONS

We suggest that the diagnostic yield for relevant endoscopic findings obtained by both the systems (ASGE and EPAGE) is low; slightly better results could be accomplished by the ASGE criteria.