Advancing a casuistic model of clinical decision making: a response to commentators

Professional judgement in clinical practice (part 3): A better alternative to strong evidence-based medicine

Parts 1 and 2 in this series of three articles have shown that and how strong evidence-based medicine has neither a coherent theoretical foundation nor creditable application to clinical practice. Because of its core commitment to the discredited positivist tradition it holds both a false concept of scientific knowledge and misunderstandings concerning clinical decision-making. Strong EBM continues attempts to use flawed adjustments to recover from the unsalvageable base view. Paper three argues that a promising solution is at hand if we can manage several modes of inclusion. A modified original, moderate version of EBM continues though usually overshadowed. As definitively laid out by Sackett in the 1990s, clinical decision making is intended to be person-centered, recognizing and integrating multiple modes of evidence and knowledge that have been marginalized: professional experience, illness narratives, and individual patients' values and preferences. Complementary resources are at hand: interpretative understanding and practice, such as philosophical anthropology, hermeneutical phenomenology, complexity theory, and phronetic practices respond to the major problems and open new possibilities. Phronesis is especially important in regard to public decision making. Within part 3 an additional tone necessarily occurs. While most of papers 1, 2, and 3 are written in the classical mode of contrasting the theoretical-logical and empirical evidence offered by contending positions bearing on the decision making and judgement in clinical practice, a shift occurs when considerations move beyond what is possible for clinical practitioners to accomplish. A different, discontinuous level of power operates in the trans-personal realm of instrumental policy, insurance, and hospital management practices. In this social-economic-political-ethical realm what happens in clinical practice today increasingly becomes a matter of what is "done unto" clinical practitioners, of what hampers their professional action and thus care of individual patients and clients.

Professional judgement in clinical practice (part 2): knowledge into practice

RATIONALE, AIMS, AND OBJECTIVES

Though strong evidence-based medicine is assertive in its claims, an insufficient theoretical basis and patchwork of arguments provide a good case that rather than introducing a new paradigm, EBM is resisting a shift to actually revolutionary complexity theory and other emergent approaches. This refusal to pass beyond discredited positivism is manifest in strong EBM's unsuccessful attempts to continually modify its already inadequate previous modifications, as did the defenders of the Ptolemaic astronomical model who increased the number of circular epicycles until the entire epicycle-deferent system proved untenable.

METHODS

Narrative Review.

RESULTS

The analysis in Part 1 of this three part series showed epistemological confusion as strong EBM plays the discredited positivistic tradition out to the end, thus repeating in a medical sphere and vocabulary the major assumptions and inadequacies that have appeared in the trajectory of modern science. Paper 2 in this series examines application, attending to strong EBM's claim of direct transferability of EBM research findings to clinical settings and its assertion of epistemological normativity. EBM's contention that it provides the "only valid" approach to knowledge and action is questioned by analyzing the troubled story of proposed hierarchies of the quality of research findings (especially of RCTs, with other factors marginalized), which falsely identifies evaluating findings with operationally utilizing them in clinical recommendations and decision-making. Further, its claim of carrying over its normative guidelines to cover the ethical responsibilities of researchers and clinicians is questioned.

Professional judgement in clinical practice (part 1): Recovering original, moderate evidence-based health care

Evidence-based medicine announced its entry as heralding a new paradigm in health care practices, but it has been widely criticized for lacking a coherent theoretical basis. This paper presents the first part of a three-article series examining the epistemological, practical, and ethical dimensions of strong EBM, as well as considering alternatives that promise potential solutions to chronic conceptual and practical problems. While the focus is on the details of the arguments and evidence in thoughtful debates over the last 30 years, it is worthwhile to keep in mind the overall trajectory of modern thought, because strong EBM continues discredited positivist positions, thus repeating its major assumptions and inadequacies, now transferred to the medical sphere and vocabulary. Part 1 of the series examines the development of strong EBM by clarifying and critiquing its somewhat discontinuous accounts of scientific knowledge and epistemology, evidence, the differences between statistical probability in regard to populations and understanding the health of individuals, and its claims for direct transfer of research findings to clinical settings-all of which raises more questions regarding its application to provider-patient decision making, pedagogy, and policy.

The EBM argument hygiene campaign

The campaign promoting evidence-based medicine (EBM) shares similarities with Joseph Lister's 19th century campaign promoting surgical antisepsis. Both target medical practitioners as their primary clients, and both appeal to these clients in the manner of a public health programme, arguing that their standards are authoritative and relevant, that the clients fail to meet them, and that this failure is a problem that requires the clients to change. Both promote hygienic solutions to the problems that they identify, the problem of microbial pathogens in the case of Lister, and the process of clinical decision making in the case of EBM. Hygienic solutions aim to operationalize standards as case-independent procedures that can be performed as habits, and seek to identify instruments of purification against sources of contamination. EBM's solution is hygienic because it characterizes clinical decision-making behaviour as a source of contamination and because it promotes a general procedure designed to correct it. Comparing the EBM campaign to Lister's helps to explain why some clinicians have had trouble trying to implement EBM as a decision-making procedure in particular cases. EBM promotes a hygienic solution, but unlike Lister, does not confront a well-defined, empirically grounded problem. Some of the difficulties with EBM stem from a mismatch between its hygienic solution and the complexity and case-dependency of clinical decision making.

Values add value: an online tool enhances postgraduate evidence-based practice learning

BACKGROUND

To better prepare practitioners for the complex world of clinical decision-making, teaching evidence-based practice needs to move beyond its focus on skills and knowledge to give students an experience and understanding of applying evidence in practice.

AIM

To explore whether incorporating an online values-based tool enhanced learning in a post graduate epidemiology course.

METHODS

Having completed a critical appraisal of an epidemiological study, students were asked to then respond to a case scenario, using the analytical frameworks of the Values-Exchange, a software tool that highlights ethical domains in decision-making. The student experience of the Values-Exchange was evaluated using focus groups. Sessions were audiotaped and transcribed. In total, 613 responses were analysed by two independent coders to identify emergent themes.

RESULTS

Three main themes emerged: (1) the Values-Exchange exposed students to new concepts and ideas relating to healthcare decision-making; (2) the diversity of other student values broadened their perspectives and (3) the experience brought reality to what it means to apply evidence in practice.

CONCLUSION

Adding an online values-based tool to clinical epidemiology teaching was highly valued by students and enabled new understandings of empirical evidence and its application in practice.

Harnessing experience: exploring the gap between evidence-based medicine and clinical practice

RATIONALE, AIMS AND OBJECTIVES

There is mounting evidence of a gap between Evidence-based Medicine (EBM) and physician clinical practice, in part because EBM is averaged global evidence gathered from exogenous populations which may not be relevant to local circumstances. Local endogenous evidence, collected in particular and 'real world' patient populations may be more relevant, convincing and timely for clinical practice. Evidence Farming (EF) is a concept to provide such local evidence through the systematic collection of clinical experience to guide more effective practice.

METHODS

We report on the findings of a pilot study of 29 individual and three focus group (n = 10) interviews exploring physicians' evaluations how they use multiple sources of information in clinical decision making and their thoughts on EF.

RESULTS

Physicians recognize a gap in translating EBM to practice. Physicians reported that when making clinical decisions, they more often rely on clinical experience, the opinions of colleagues and EBM summarizing electronic clinical resources rather than refer directly to EBM literature. Confidence in making decisions based on clinical experience increases over time, yet few physicians reported having systems for tracking their clinical experience in designing treatment plans and patient outcomes. Most physicians saw EF as a promising way to track experience, thereby making scientific evidence more relevant to their own clinical practices.

CONCLUSION

Clinical experience is relatively neglected by the EBM movement, but if that experience were systematically gathered through an approach such as EF, it would meet a need left unfulfilled by EBM.