Reductionist inference-based medicine, i.e. EBM

Person-centred health care: a critical assessment of current and emerging research approaches

RATIONALE, AIMS AND OBJECTIVES

Person-centred health care is prominent in international health care reforms. A shift to understanding and improving personal care at the point of delivery has generated debates about the nature of the person-centred research agenda. This paper purviews research paradigms that influence current person-centred research approaches and traditions that influence knowledge foundations in the field. It presents a synthesis of the emergent approaches and methodologies and highlights gaps between static academic research and the increasing accessibility of evaluation, informatics and big data from health information systems.

FINDINGS

Paradigms in health services research range from theoretical to atheoretical, including positivist, interpretive, postmodern and pragmatic. Interpretivist (subjective) and positivist (objectivist) paradigms have been historically polarized. Yet, integrative and pragmatic approaches have emerged. Nevertheless, there is a tendency to reductionism, and to reduce personal experiences to metrics in the positivist paradigm. Integrating personalized information into clinical systems is increasingly driven by the pervasive health information technology, which raises many issues about the asymmetry and uncertainty in the flow of information to support personal health journeys. The flux and uncertainty of knowledge between and within paradigmatic or pragmatic approaches highlights the uncertainty and the 'unorder and disorder' in what is known and what it means. Transdisciplinary, complex adaptive systems theory with multi-ontology sense making provides an overarching framework for making sense of the complex dynamics in research progress.

CONCLUSION

A major challenge to current research paradigms is focus on the individualizing of care and enhancing experiences of persons in health settings. There is an urgent need for person-centred research to address this complex process. A transdisciplinary and complex systems approach provides a sense-making framework.

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.

Decontextualized versus lived worlds: critical thoughts on the intersection of evidence, lifeworld, and values

BACKGROUND

Numerous studies and trials are conducted under the evidence-based complementary and alternative medicine (EBCAM) paradigm. Some individuals view the results generated by this approach as symbolic evidential proof of complementary medicine, and as representative of practice. Such evaluations are made even though the ability to capture and reflect clinical reality by the methods used is questioned. The effect of this type of research on complementary medicine researchers and practitioners has received minimal consideration, and this article explores this subject by critically reviewing the literature and theorizing the effects on the lifeworld and values of those embodied by EBCAM.

METHODS

This review accesses the discourse of various disciplines involved with, and commenting on, complementary medicine research. Collected literature is collated within specified limits, subjected to argumentation analysis, and synthesized within a critical theory methodology. Emergent themes are examined, and the effects of EBCAM on holistic researcher and practitioner lifeworld and values are theorized via the colonization framework of critical social theorist Jürgen Habermas.

RESULTS

The use of an evidence-based medicine research model to investigate complementary medicine practice is not well regarded by those who critically examine its use. Within a critical theory framework, the generation and application of research resulting from EBCAM is viewed as a philosophically incongruent process arising from a dominative discourse that can colonize lifeworld. This can result in a variety of pathological symptoms that may have a detrimental effect.

CONCLUSIONS

The application of EBCAM has the theoretical potential to damage complementary medicine culture, profession, and practice. Its ongoing use requires thought, attention, and careful revision, taking into account the lifeworld and values of researchers and practitioners. If this inclusive view can occur, knowledge generation with relevance to the whole of the professions could proceed.

W(h)ither complexity? The emperor's new toolkit? Or elucidating the evolution of health systems knowledge?

RATIONALE

The outputs from vastly expanding health research and knowledge industry with a broadening range of approaches to the synthesis of knowledge provide an impetus to develop complex science and theory-informed knowledge management in health care. Aims To stimulate debate in order to assist health care decision makers to move beyond framing certainty and evidence in purely reductionist terms.

OBJECTIVES

To locate health, health care and health knowledge systems research using a complex adaptive systems theory framework. Methods An conceptual analysis of pervading methodologies and ways of knowing in health systems research to elucidate a framework in order to inform health care decision making.

FINDINGS

A living Tree of (Research) Knowledge is proposed, with theoretic and operational frameworks. Branches of the tree are linked to differing evolutionary and developmental processes in order to assist researchers in the ongoing self-organizing of taxonomies, multiple methods and types of knowledge, recognizing the 'lived', developing and adaptive nature of our understandings.

CONCLUSIONS

It is challenging to determine whither the directions 'knowledge' creation and management should take in complex health systems, beyond a total reliance on reductionism. Yet quality will wither, if knowledge does not pertain to real world contexts.

Translational systems biology and voice pathophysiology

OBJECTIVES/HYPOTHESIS

Personalized medicine has been called upon to tailor healthcare to an individual's needs. Evidence-based medicine (EBM) has advocated using randomized clinical trials with large populations to evaluate treatment effects. However, due to large variations across patients, the results are likely not to apply to an individual patient. We suggest that a complementary, systems biology approach using computational modeling may help tackle biological complexity in order to improve ultimate patient care. The purpose of the article is: 1) to review the pros and cons of EBM, and 2) to discuss the alternative systems biology method and present its utility in clinical voice research.

STUDY DESIGN

Tutorial.

METHODS

Literature review and discussion.

RESULTS

We propose that translational systems biology can address many of the limitations of EBM pertinent to voice and other health care domains, and thus complement current health research models. In particular, recent work using mathematical modeling suggests that systems biology has the ability to quantify the highly complex biologic processes underlying voice pathophysiology. Recent data support the premise that this approach can be applied specifically in the case of phonotrauma and surgically induced vocal fold trauma, and may have particular power to address personalized medicine.

CONCLUSIONS

We propose that evidence around vocal health and disease be expanded beyond a population-based method to consider more fully issues of complexity and systems interactions, especially in implementing personalized medicine in voice care and beyond.

Creating synergy in practice: promoting complementarity between evidence-based and postmodern approaches

Postmodern and evidence-based practice (EBP) are compared and contrasted with the primary aim of adapting evidence-based practice with a more flexible epistemological lens. We begin by reviewing the epistemological underpinnings of postmodern and EBP within the field of marriage and family therapy (MFT). We next discuss how these contrasting philosophies inform therapists' traits and practice in the context of translational research and practice-based evidence. Finally, we point toward some promising directions for a flexible adaptation of evidence-based practice in which both modern and postmodern clinicians can practice, and ways to incorporate some of these more flexible principles into the clinical training of MFT students.

The increasing complexities of professionalism

Organized medicine's modern-day professionalism movement has reached the quarter-century mark. In this article, the authors travel to an earlier time to examine the concept of profession within the work of Abraham Flexner. Although Flexner used the concept sparingly, it is clear that much of his writing on reforming medical education is grounded in his views on physicians as professionals and medicine as a profession. In the first half, the authors explore Flexner's views of profession, which were (1) empirically (as opposed to philosophically) grounded, (2) case based and comparatively framed, (3) sociological in orientation, and (4) systems based, with professionalism conceptualized as dynamic, evolving, and multidimensional. In the second half, the authors build on Flexner's systems perspective to introduce a complexity science understanding of professionalism. They define professionalism as a complex system, introduce a seven-part typology of professionalism, and explore how the organization of physician work and various flash points within medicine today reveal not one but several competing forms of professionalism at work. The authors then develop a tripartite model of professionalism with analysis at the micro, meso, and macro levels. They conclude with observations on how best to frame professionalism as a force for change in 21st-century medical education. Flexner's reforms were grounded in his vision of two particular types of professional-the physician clinician and the full-time academic physician-scientist. The authors propose reform grounded in professionalism as a complex system composed of competing types.

Redescribing reflective practice and evidence-based practice discourses

This paper provides an analysis on the discourses of reflective practice and evidence-based practice. It commences by examining the role of discourse in describing and defining our beliefs and attitudes. Consequently, it argues that each discourse is based on a certain epistemology, which in effect are language constructs that create realities and like all language constructs, the epistemology of each discourse is open to the possibility of being restructured. Sequentially, any discourse can (re)describe a different type of reality by providing a set of different words, values and beliefs. Eventually, by exposing the language play and the engineered binary of the reflective practice and the evidence-based practice discourses it is concluded that these discourses are not mutually exclusive as they have been portrayed by most of the literature, but complementary ones. Finally, reflective practice and evidence-based practice are re-described as supplementary discourses and practitioners can simultaneously utilize both through the process of critical reflexivity.

The use of postcolonialism in the nursing domain: colonial patronage, conversion, and resistance

The current context in nursing requires radical political analyses to deconstruct the dominant discourses that map both the discipline and the profession. In response to the strong reaction to articles, which critically examined the evidence-based movement in health sciences, we believe that it is essential to offer a perspective that is capable of resisting the progress of such discourses, which currently prevail in nursing and thus shape our profession. We believe that the biomedical model/ideology is a form of colonial patronage that is becoming more and more influential in nursing. Such colonization takes the forms of powerful discourses (eg, evidence-based medicine) and institutional practices that pervade all spheres of nursing: practice, research, education, and administration. In previous articles, we have criticized this trend; consequently, the objective of this article is not to replicate our previous arguments but rather to demonstrate that to what extent a postcolonial approach to nursing constitutes an efficient tool for disrupting the colonizing effects of the biomedical discourse.

The evidence-based practice ideologies

This paper puts forward the argument that there are various, competing, and antithetical evidence-based practice (EBP) definitions and acknowledges that the different EBP definitions are based on different epistemological perspectives. However, this is not enough to understand the way in which nurse professionals choose between the various EBP formations and consequently facilitate them in choosing the most appropriate for their needs. Therefore, the current article goes beyond and behind the various EBP epistemologies to identify how individuals choose an epistemology, which consequently will assist our understanding as to how an individual chooses a specific EBP formation. Individuals choose an epistemology on the mere belief that the specific epistemology offers the ideals or ideas of best explaining or interpreting daily reality. These ideals or ideas are termed by science, history, and politics as ideology. Similarly, individual practitioners choose or should choose between the different EBP formations based on their own personal ideology. Consequently, this article proceeds to analyse the various ideologies behind different EBP definitions as to conclude that there are two broad ideologies that inform the various EBP formations, namely the ideology of truth and the ideology of individual emancipation. These two ideologies are analysed and their connections to the various EBP formations are depicted. Eventually, the article concludes that the in-depth, critical, and intentional analysis by individual nurses of their own ideology will allow them to choose the EBP formation that is most appropriate and fitting for them, and their specific situation. Hence, the conscious analysis of individual ideology becomes the criterion for choosing between competing EBP formations and allows for best evidence to be implemented in practice. Therefore, the best way to teach EBP courses is by facilitating students to analyse their own ideology.

A review of evidence-based practice, nursing research and reflection: levelling the hierarchy

AIM

This paper examines the evidence-based practice movement, the hierarchy of evidence and the relationship between evidence-based practice and reflective practice.

BACKGROUND

Evidence-based practice is equated with effective decision making, with avoidance of habitual practice and with enhanced clinical performance. The hierarchy of evidence has promoted randomized control trials as the most valid source of evidence. However, this is problematic for practitioners as randomized control trials overlook certain types of knowledge that, through the process of reflection, provide useful information for individualized and effective practice.

METHOD

A literature search was undertaken using CINAHL, medline and Ovid electronic databases in early 2006. The search terms used were: evidence-based practice, research evidence, evidence for practice, qualitative research, reflective practice, reflection and evidence. Other sources included handpicking of books on evidence-based practice, reflection and research. Only material written in English was included.

FINDINGS

The hierarchy of evidence that has promoted randomized control trials as the most valid form of evidence may actually impede the use of most effective treatment because of practical, political/ideological and epistemological contradictions and limitations. Furthermore, evidence-based practice appears to share very similar definitions, aims and procedures with reflective practice. Hence, it appears that the evidence-based practice movement may benefit much more from the use of reflection on practice, rather than the use of the hierarchical structure of evidence.

CONCLUSION

Evidence-based practice is necessary for nursing, but its' effective implementation may be hindered by the hierarchy of evidence. Furthermore, evidence-based practice and reflection are both processes that share very similar aims and procedures. Therefore, to enable the implementation of best evidence in practice, the hierarchy of evidence might need to be abandoned and reflection to become a core component of the evidence-based practice movement.

RELEVANCE TO CLINICAL PRACTICE

Provides an elaborated analysis for clinical nurses on the definition and implementation of evidence in practice.