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Loughlin M. Inspecting the links: Knowledge, evidence and value in healthcare. J Eval Clin Pract 2024; 30:729-734. [PMID: 39083553 DOI: 10.1111/jep.14081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 06/22/2024] [Indexed: 08/02/2024]
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2
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Arnold MH, Kerridge I. Patient-centricity: Research's new shibboleth? J Eval Clin Pract 2023. [PMID: 36890625 DOI: 10.1111/jep.13830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Affiliation(s)
- Mark H Arnold
- Rural Clinical School (Dubbo and Orange) Sydney Medical Program, Sydney School of Public Health, Sydney Health Ethics the University of Sydney, New South Wales, Australia
| | - Ian Kerridge
- Sydney School of Public Health the University of Sydney, Royal North Shore Hospital, Sydney Health Ethics, Sydney, New South Wales, Australia
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3
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Marcum JA. Patient-oriented research and the shiny object syndrome. J Eval Clin Pract 2023. [PMID: 36866413 DOI: 10.1111/jep.13826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 03/04/2023]
Affiliation(s)
- James A Marcum
- Department of Philosophy, Baylor University, Waco, Texas, USA
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4
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A C, A S, A G, Pj O. An exploration of the clinical reasoning used by registered osteopaths in their choice of therapeutic approach. INT J OSTEOPATH MED 2022. [DOI: 10.1016/j.ijosm.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Manoharan R, Kemper J, Young J. Exploring the medical cannabis prescribing behaviours of New Zealand physicians. Drug Alcohol Rev 2022; 41:1355-1366. [PMID: 35604868 PMCID: PMC9544511 DOI: 10.1111/dar.13476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Many countries are changing their regulations for prescribing medical cannabis. As gatekeepers, physicians significantly impact patient access to cannabis treatments. It is important to explore how physicians view prescribing cannabis in terms of their existing beliefs, knowledge, possible concerns and personal perceptions. METHODS Individual, semi-structured telephone interviews were undertaken with 14 New Zealand physicians from various specialties. The interviews were thematically analysed using a phenomenological approach. RESULTS The physician-patient relationship was of extreme importance in making prescription decisions, driven largely by trust in the patient. Barriers to prescribing included concern over possible side effects, the quality and standardisation of medication, uncertainty about indications and equity concerns from the high cost for lower socio-economic patients. Some physicians held concerns over their liability and risks to their reputation if issues arose for patients. DISCUSSION AND CONCLUSION The way physicians regard prescribing medical cannabis is based on their personal beliefs and knowledge built up over their medical career. It is important that these are taken into consideration in the design of future guidelines to help alleviate uncertainties and reduce barriers for informed prescribing. While our research and previous research find that physicians generally will follow clinical guidelines based on institutional logics (i.e. the standardised approach to medicine), we find that physicians often allow their personal construals to determine their perceptions and prescribing behaviour to a considerable extent when they practice medicine. Our findings have implications for Continuing Medical Education, marketing and regulation for medical cannabis, especially about the wording of guideline adherence.
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Affiliation(s)
- Rachel Manoharan
- School of Biological SciencesUniversity of AucklandAucklandNew Zealand
| | - Joya Kemper
- Department of Management, Marketing and EntrepreneurshipUniversity of Canterbury, UC Business SchoolChristchurchNew Zealand
| | - Jenny Young
- Plant and Food Research LtdAucklandNew Zealand
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6
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Veziari Y, Kumar S, Leach MJ. An exploration of barriers and enablers to the conduct and application of research among complementary and alternative medicine stakeholders in Australia and New Zealand: A qualitative descriptive study. PLoS One 2022; 17:e0264221. [PMID: 35180276 PMCID: PMC8856519 DOI: 10.1371/journal.pone.0264221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 02/06/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Most studies examining complementary and alternative medicine (CAM) stakeholder engagement with evidence-based practice have relied on quantitative research methods, which often fail to capture the nuances of this phenomena. Using qualitative methods, this study aimed to explore the experiences of CAM stakeholders regarding the barriers and enablers to the conduct and application of research. METHODS This research was guided by a qualitative descriptive framework. CAM practitioners and researchers of multiple CAM disciplines from across Australia and New Zealand were invited to share their personal perspectives of the study phenomena. Semi-structured interviews were conducted via Zoom, which were audio-recorded and transcribed verbatim. Rigour strategies were applied to ensure the credibility of results. The transcript was analysed using thematic analysis. RESULTS CAM stakeholders identified an array of barriers and enablers to the conduct and application of research within their disciplines. The barriers and enablers that emerged were found to be inter-connected with two similar constructs: capacity and culture. Captured within the construct of capacity were five themes-lack of resources, inadequate governance/leadership, lack of competency, bias directed from outside and within CAM, and lack of time for research. Within the construct of culture were two themes-intrinsic perceptions in CAM, and lack of communication within and outside CAM. CONCLUSIONS Promoting evidence-based practice and engaging with research in CAM continues to face challenges. This study, for the first time, has highlighted the multitude of interlinked barriers that confront CAM stakeholders when engaging with research. These findings highlight the need for a concerted and targeted approach to tackle these challenges.
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Affiliation(s)
- Yasamin Veziari
- UniSA Allied Health & Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, Australia
| | - Saravana Kumar
- UniSA Allied Health & Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, Australia
| | - Matthew J. Leach
- Southern Cross University, National Centre for Naturopathic Medicine, East Lismore, New South Wales, Australia
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7
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Sawyers L, Anderson C, Boyd MJ, Hessel V, Wotring V, Williams PM, Toh LS. Astropharmacy: Pushing the boundaries of the pharmacists’ role for sustainable space exploration. Res Social Adm Pharm 2022; 18:3612-3621. [DOI: 10.1016/j.sapharm.2022.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/28/2022] [Accepted: 02/07/2022] [Indexed: 01/01/2023]
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Demergazzi S, Pastore L, Bassani G, Arosio M, Lonati C. Information Needs and Information-Seeking Behavior of Italian Neurologists: Exploratory Mixed Methods Study. J Med Internet Res 2020; 22:e14979. [PMID: 32181742 PMCID: PMC7177431 DOI: 10.2196/14979] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 12/22/2019] [Accepted: 02/03/2020] [Indexed: 01/25/2023] Open
Abstract
Background Current medical professions involve an extensive knowledge of the latest validated scientific data to implement disease diagnosis, therapeutic strategies, and patient care. Although clinicians can refer to a growing number and type of information sources to keep current with new scientific achievements, there are still various concerns about medical information validity, quality, and applicability into clinical practice. Novel strategies are required to identify physicians’ real-life needs with the final aim to improve modern medical information delivery. Objective Our research used an innovative tool to collect real-time physician queries in order to investigate information needs and seeking behavior of Italian neurologists treating patients with multiple sclerosis (MS) and migraine. Methods The study was designed as an exploratory mixed methods (ie, qualitative and quantitative) study involving 15 consecutive days of observation. A total of 50 neurologists (n=25 MS and n=25 migraine specialists) were recruited. Data were collected using an instant messaging mobile app designed for this research. At each information-seeking event, moderators triggered a computer-assisted personal interview including both semistructured interview and close-ended questions. Interactions and physician queries collected using the mobile app were coded into emerging themes by content analysis. Results Neurologist queries were relevant to the following major themes: therapy management (36/50, 71%) and drug-related information (34/50, 67%), followed by diagnostic strategies and procedures (21/50, 42%). Quantitative analysis indicated online resources were preferentially used by clinicians (48/50, 96%) compared with offline sources (24/50, 47%). A multichannel approach, in which both online and offline sources were consulted to meet the same need, was adopted in 33% (65/198) of information-seeking events. Neurologists more likely retrieved information from online relative to offline channels (F=1.7; P=.01). MS specialists were 53% more likely to engage in one information-seeking event compared with migraine neurologists (risk ratio 1.54; 95% CI 1.16-2.05). MS specialists tended to be more interested in patient-related content than migraine clinicians (28% [7/25] vs 10% [2/25], P=.06), who conversely more likely sought information concerning therapy management (85% [21/25] vs 60% [15/25], P=.05). Compared with MS clinicians, migraine specialists had a harder time finding the required information, either looking at online or offline channels (F=12.5; P=.01) and less frequently used offline channels (30% [8/25] vs 60% [15/25] of information-seeking events, P=.02). When multiple sources needed to be consulted to retrieve an information item, a reduced satisfaction rate was observed both among migraine and MS specialists (single source vs multiple sources P=.003). Conclusions This study provides a detailed description of real-life seeking behavior, educational needs, and information sources adopted by Italian MS and migraine neurologists. Neurologist information needs and seeking behavior reflect the specific characteristics of the specialty area in which they operate. These findings suggest identification of time- and context-specific needs of clinicians is required to design an effective medical information strategy.
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Affiliation(s)
| | - Luca Pastore
- Medical Information Department, Teva Italia Srl, Assago, Italy
| | | | - Marco Arosio
- Research Department, Doxa Pharma Srl, Milan, Italy
| | - Caterina Lonati
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Healy P. Rethinking the doctor-patient relationship: toward a hermeneutically-informed epistemology of medical practice. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:287-295. [PMID: 30414062 DOI: 10.1007/s11019-018-9875-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Although typically implicit, clinicians face an inherent conflict between their roles as medical healers and as providers of technical biomedicine (Scott et al. in Philos Ethics Humanit Med 4:11, 2009). This conflict arises from the tension between the physicalist model which still predominates in medical training and practice and the extra-physicalist dimensions of medical practice as epitomised in the concept of patient-centred care. More specifically, the problem is that, as grounded in a "borrowed" physicalist philosophy, the dominant "applied scientist" model exhibits a number of limitations which severely restrict its ability to underwrite the effective practice of care. Moreover, being structural in character, these problems cannot be resolved by piecemeal modifications of the existing model, nor by an appeal to evidence-based medicine (Miles in J Eval Clin Pract 15(6):887-890, 2009; Miles in Folia Med 55(1):5-24, 2013; Miles et al. in J Eval Clin Pract 14(5):621-649, 2008). Hence, the need for medical theorists to "partner with experts in the humanities to build a sui generis philosophy of medicine" (Whatley in J Eval Clin Pract 20(6):961-964, 2014, p. 961). In response, the present paper seeks to vindicate the merits of hermeneutically-informed template in providing the requisite grounding. While capable of correcting for the limitations of the applied scientist model, a hermeneutically-informed template is a "both/and" approach, which seeks to complement rather than exclude the physicalist dimension, and thereby aspires to reconcile technical mastery with patient-centred care, rather than eschew one in favour of the other. As such, it can provide a cogent philosophical template for current best practice, which does justice to the art as well as the science of medical care.
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Affiliation(s)
- Paul Healy
- Faculty of Health, Arts, and Design, Swinburne University of Technology, John Street, Hawthorn, VIC, 3122, Australia.
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Sundberg T, Leach MJ, Thomson OP, Austin P, Fryer G, Adams J. Attitudes, skills and use of evidence-based practice among UK osteopaths: a national cross-sectional survey. BMC Musculoskelet Disord 2018; 19:439. [PMID: 30526551 PMCID: PMC6286591 DOI: 10.1186/s12891-018-2354-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 11/20/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Evidence-based practice (EBP) is a clinical decision-making framework that supports quality improvement in healthcare. While osteopaths are key providers of musculoskeletal healthcare, the extent to which osteopaths engage in EBP is unclear. Thus, the aim of this cross-sectional study was to investigate UK osteopaths' attitudes, skills and use of EBP, and perceived barriers and facilitators of EBP uptake. METHODS UK-registered osteopaths were invited to complete the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) online. RESULTS Of the 5200 registered osteopaths in the UK, 9.9% (517/5200) responded to the invitation, and 7.2% (375/5200) completed the EBASE (< 20% incomplete answers). The demographic characteristics of the survey sample were largely similar to those of the UK osteopathy workforce. The osteopaths reported overall positive attitudes towards EBP, with most agreeing that EBP improves the quality of patient care (69.3%) and is necessary for osteopathy practice (76.5%). The majority reported moderate-level skills in EBP, and most (80.8%) were interested in improving these skills. Participating osteopaths typically engaged in EBP activities 1-5 times over the last month. Barriers to EBP uptake included a lack of time and clinical evidence in osteopathy. Main facilitators of EBP included having access to online databases, internet at work, full-text articles, and EBP education materials. CONCLUSIONS UK osteopaths were generally supportive of evidence-based practice, had moderate-level skills in EBP and engaged in EBP activities infrequently. The development of effective interventions that improve osteopaths' skills and the incorporation of EBP into clinical practice should be the focus of future research.
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Affiliation(s)
- Tobias Sundberg
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, NSW Australia
- Musculoskeletal and Sports Injury Epidemiology Center (MUSIC), Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Matthew J. Leach
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, NSW Australia
- Department of Rural Health, University of South Australia, Adelaide, Australia
| | - Oliver P. Thomson
- University College of Osteopathy, London, UK
- Clinical-based Human Research Department, Centre for Osteopathic Medicine Collaboration (COME), Pescara, Italy
| | - Philip Austin
- Department of Pain Management, Greenwich Hospital, Sydney, Australia
| | - Gary Fryer
- Institute for Health and Sport, Victoria University, Melbourne, Victoria Australia
| | - Jon Adams
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, NSW Australia
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Paez A. The "architect analogy" of evidence-based practice: Reconsidering the role of clinical expertise and clinician experience in evidence-based health care. J Evid Based Med 2018; 11:219-226. [PMID: 30444073 DOI: 10.1111/jebm.12321] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2018] [Indexed: 01/11/2023]
Abstract
The role of expertise in evidence-based medicine (EBM) and practice (EBP) has long been debated. In the early years of the EBP movement, the role of expertise and experience were diminished in clinical decision-making. However, the concepts of EBP are evolving. A more nuanced view of the value of clinician expertise, based on experience and clinical judgement, has emerged. This article proposes that clinical expertise does not belong within the evidence hierarchy's decision-making pyramid as the lowest form of evidence, but rather alongside it, representing a complementary source of knowledge that supports the processes of EBP. An "Architect Analogy of EBP" is proposed as a new model by which to describe this relationship. In this analogy, the clinician's use of expertise is likened to the role of an architect, using evidence as building blocks in the construction of the client's edifice, representing the patients' health and wellbeing. Much as an architect carefully designs the edifice in consultation with the client's needs and preferences, choosing appropriate material (evidence), rejecting faulty material, and ensuring construction stays on course, the clinician must sort through a plethora of sometimes contradictory evidence, evaluate its merits and appropriateness for the patients' unique biopsychosocial circumstances and values, and monitor the effects of interventions on patients' health and wellbeing. The expertise of practitioners, as the architects of EBP, is an important supporting source of knowledge that facilitates the "Five Steps of EBP," informs and facilitates EBP, and supports patient-centred care.
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Affiliation(s)
- Arsenio Paez
- Nuffield Department of Primary Care Health Sciences, Department for Continuing Education, The University of Oxford, Oxford, UK
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Leach MJ, Canaway R, Hunter J. Evidence based practice in traditional & complementary medicine: An agenda for policy, practice, education and research. Complement Ther Clin Pract 2018; 31:38-46. [PMID: 29705478 DOI: 10.1016/j.ctcp.2018.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/29/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To develop a policy, practice, education and research agenda for evidence-based practice (EBP) in traditional and complementary medicine (T&CM). METHODS The study was a secondary analysis of qualitative data, using the method of roundtable discussion. The sample comprised seventeen experts in EBP and T&CM. The discussion was audio-recorded, and the transcript analysed using thematic analysis. RESULTS Four central themes emerged from the data; understanding evidence and EBP, drivers of change, interpersonal interaction, and moving forward. Captured within these themes were fifteen sub-themes. These themes/sub-themes translated into three broad calls to action: (1) defining terminology, (2) defining the EBP approach, and (3) fostering social movement. These calls to action formed the framework of the agenda. CONCLUSIONS This analysis presents a potential framework for an agenda to improve EBP implementation in T&CM. The fundamental elements of this action plan seek clarification, leadership and unification on the issue of EBP in T&CM.
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Affiliation(s)
- Matthew J Leach
- Department of Rural Health, University of South Australia, North Terrace, Adelaide, SA, 5000, Australia.
| | - Rachel Canaway
- Department of General Practice, The University of Melbourne, 200 Berkeley St, Victoria, 3010, Australia.
| | - Jennifer Hunter
- NICM, Western Sydney University, Campbelltown Campus, Locked Bag 1797, Penrith NSW, 2751, Australia.
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Loughlin M, Bluhm R, Buetow S, Borgerson K, Fuller J. Reasoning, evidence, and clinical decision-making: The great debate moves forward. J Eval Clin Pract 2017; 23:905-914. [PMID: 28960730 DOI: 10.1111/jep.12831] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/16/2017] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Michael Loughlin
- Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK
| | - Robyn Bluhm
- Department of Philosophy, Lyman Briggs College, Michigan State University, East Lancing, Michigan, USA
| | - Stephen Buetow
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | | | - Jonathan Fuller
- African Centre for Epistemology and Philosophy of Science, University of Johannesburg, Johannesburg, South Africa.,Toronto Philosophy of Medicine Network, University of Toronto, Toronto, Canada
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Abstract
Background: In the third and final article in this three part series, I look at sampling in qualitative studies, methods of data collection and analysis. Content: Building on the previous two articles, I highlight the importance of rigour and explore some of the different criteria used by researchers to demonstrate that their research is trustworthy. I include a brief discussion of some of the more recent trends in mixed-method or post-positivist research. Conclusions: Qualitative research is different in many ways to quantitative, and it cannot be approached with the same mind-set. It seeks to explore different aspects to quantitative research, focusing on the individual experience, rather than conclusions that can be drawn from large groups. Because of these differences, the two approaches to research should not be seen as alternatives, but complementary.
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Affiliation(s)
- David Nicholls
- Senior lecturer, Auckland University of Technology, Faculty of Health and Environmental Sciences, Auckland, New Zealand
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Senior AM, Gosby AK, Lu J, Simpson SJ, Raubenheimer D. Meta-analysis of variance: an illustration comparing the effects of two dietary interventions on variability in weight. EVOLUTION MEDICINE AND PUBLIC HEALTH 2016; 2016:244-55. [PMID: 27491895 PMCID: PMC4981479 DOI: 10.1093/emph/eow020] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/27/2016] [Indexed: 01/01/2023]
Abstract
New meta-analysis methods from evolutionary biology allow us to ask how treatments affect variability, as opposed to just the average. Using these methods we demonstrate that low carbohydrate ad libitum diets may have more variable outcomes than calorie restricted diets. Meta-analysis, which drives evidence-based practice, typically focuses on the average response of subjects to a treatment. For instance in nutritional research the difference in average weight of participants on different diets is typically used to draw conclusions about the relative efficacy of interventions. As a result of their focus on the mean, meta-analyses largely overlook the effects of treatments on inter-subject variability. Recent tools from the study of biological evolution, where inter-individual variability is one of the key ingredients for evolution by natural selection, now allow us to study inter-subject variability using established meta-analytic models. Here we use meta-analysis to study how low carbohydrate (LC) ad libitum diets and calorie restricted diets affect variance in mass. We find that LC ad libitum diets may have a more variable outcome than diets that prescribe a reduced calorie intake. Our results suggest that whilst LC diets are effective in a large proportion of the population, for a subset of individuals, calorie restricted diets may be more effective. There is evidence that LC ad libitum diets rely on appetite suppression to drive weight loss. Extending this hypothesis, we suggest that between-individual variability in protein appetite may drive the trends that we report. A priori identification of an individual’s target intake for protein may help define the most effective dietary intervention to prescribe for weight loss.
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Affiliation(s)
| | - Alison K Gosby
- Charles Perkins Centre School of Life and Environmental Sciences
| | | | | | - David Raubenheimer
- Charles Perkins Centre School of Life and Environmental Sciences Faculty of Veterinary Sciences, The University of Sydney, Sydney, New South Wales 2006, Australia
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Miles A. From EBM to PCH: always predictable, now inexorable. Editorial Introduction to the 2015 Evidence Based Medicine Thematic Issue of the Journal of Evaluation in Clinical Practice. J Eval Clin Pract 2015; 21:983-7. [PMID: 26915829 DOI: 10.1111/jep.12525] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/23/2015] [Indexed: 12/22/2022]
Affiliation(s)
- Andrew Miles
- Journal of Evaluation in Clinical Practice & Senior Vice President/Secretary General, European Society for Person Centered Healthcare, Faculty of Medicine, Francisco de Vitoria University, Madrid, Spain.,Faculty of Medicine, Imperial College, London, UK
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Tregarthen JP, Lock J, Darcy AM. Development of a smartphone application for eating disorder self-monitoring. Int J Eat Disord 2015. [PMID: 26213130 DOI: 10.1002/eat.22386] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE This case report aims to (1) describe the development and refinement of a smartphone application for eating disorder self-monitoring; (2) characterize its users in terms of demographic and clinical characteristics; and (3) explore its feasibility and utilization as a self-monitoring tool. METHOD We developed a mobile phone application through which people with eating disorders can self-monitor meals, emotions, behaviors, and thoughts. The application also included positive reinforcement, coping skill suggestions, social support, and feedback components. The app was made available on two Internet app stores. Data include number of downloads and subsequent usage statistics, consumer ratings on app-stores are used as indicators of satisfaction, anonymous aggregate demographic data and Eating Disorder Examination Questionnaire scores from 57,940 individuals collected over a two-year period. RESULTS The app demonstrated population-level utilization with over 100,000 users over a two-year period. Almost 50% percent of users stated that they are not currently receiving clinical treatment and 33% reported they had not told anyone about their eating disorder. A surprising number of people with severe problems are using the app. DISCUSSION Smartphone apps have the capacity to reach and engage traditionally underserved individuals with eating disorders at a large scale. Additional work is indicated for the evaluation of the clinical effectiveness of applications for specific user groups and in clinical treatment contexts.
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Affiliation(s)
| | - James Lock
- Department of Psychiatry and Behavioral Medicine, Stanford University School of Medicine, Stanford, California
| | - Alison M Darcy
- Department of Psychiatry and Behavioral Medicine, Stanford University School of Medicine, Stanford, California
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Challenges and Opportunities for Exploring Patient-Level Data. BIOMED RESEARCH INTERNATIONAL 2015; 2015:150435. [PMID: 26504779 PMCID: PMC4609340 DOI: 10.1155/2015/150435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/27/2015] [Indexed: 11/28/2022]
Abstract
The proper exploration of patient-level data will pave the way towards personalised medicine. To better assess the state of the art in this field we identify the challenges and uncover the opportunities for the exploration of patient-level data through the review of well-known initiatives and projects focusing on the exploration of patient-level data. These cover a broad array of topics, from genomics to patient registries up to rare diseases research, among others. For each, we identified basic goals, involved partners, defined strategies and key technological and scientific outcomes, establishing the foundation for our analysis framework with four pillars: control, sustainability, technology, and science.
Substantial research outcomes have been produced towards the exploration of patient-level data. The potential behind these data will be essential to realise the personalised medicine premise in upcoming years. Hence, relevant stakeholders continually push forward new developments in this domain, bringing novel opportunities that are ripe for exploration.
Despite last decade's translational research advances, personalised medicine is still far from being a reality. Patients' data underlying potential goes beyond daily clinical practice. There are miscellaneous challenges and opportunities open for the exploration of these data by academia and business stakeholders.
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Tsang S. Arrow physicians: are economics and medicine philosophically incompatible? J Eval Clin Pract 2015; 21:419-26. [PMID: 25850973 DOI: 10.1111/jep.12348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 12/14/2022]
Abstract
Economics is en route to its further expansion in medicine, but many in the medical community remain unconvinced that its impact will be positive. Thus, a philosophical enquiry into the compatibility of economics and medicine is necessary to resolve the disagreements. The fundamental mission of medicine obliges physicians to practise science and compassion to serve the patient's best interests. Conventional (neoclassical) economics assumes that individuals are self-interested and that competitive markets will emerge optimal states. Economics is seemingly incompatible with the emphasis of putting patients' interests first. This idea is refuted by Professor Kenneth Arrow's health economics seminal paper. Arrow emphasizes that medical practice involves agency, knowledge, trust and professionalism, and physician-patient relation critically affects care quality. The term Arrow Physician is used to mean a humanistic carer who has a concern for the patient and acts on the best available evidence with health equity in mind. To make this practice sustainable, implementing appropriate motivations, constitutions and institutions to enable altruistic agency is critical. There is substantial evidence that polycentric governance can encourage building trust and reciprocity, so as to avoid depletion of communal resources. This paper proposes building trusting institutions through granting altruistic physicians adequate autonomy to direct resources based on patients' technical needs. It also summarizes the philosophy bases of medicine and economics. It, therefore, contributes to developing a shared language to facilitate intellectual dialogues, and will encourage trans-disciplinary research into medical practice. This should lead to medicine being reoriented to care for whole persons again.
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Affiliation(s)
- Sandro Tsang
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong; Peoples Open Access Education Initiative, Manchester, UK
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Fernandez AV, Wieten S. Values-based practice and phenomenological psychopathology: implications of existential changes in depression. J Eval Clin Pract 2015; 21:508-13. [PMID: 25832560 DOI: 10.1111/jep.12313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2014] [Indexed: 12/13/2022]
Abstract
Values-based practice (VBP), developed as a partner theory to evidence-based medicine (EBM), takes into explicit consideration patients' and clinicians' values, preferences, concerns and expectations during the clinical encounter in order to make decisions about proper interventions. VBP takes seriously the importance of life narratives, as well as how such narratives fundamentally shape patients' and clinicians' values. It also helps to explain difficulties in the clinical encounter as conflicts of values. While we believe that VBP adds an important dimension to the clinician's reasoning and decision-making procedures, we argue that it ignores the degree to which values can shift and change, especially in the case of psychiatric disorders. VBP does this in three respects. First, it does not appropriately engage with the fact that a person's values can change dramatically in light of major life events. Second, it does not acknowledge certain changes in the way people value, or in their modes of valuing, that occur in cases of severe psychiatric disorder. And third, it does not acknowledge the fact that certain disorders can even alter the degree to which one is capable of valuing anything at all. We believe that ignoring such changes limits the degree to which VBP can be effectively applied to clinical treatment and care. We conclude by considering a number of possible remedies to this issue, including the use of proxies and written statements of value generated through interviews and discussions between patient and clinician.
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Polivka J, Polivka J, Karlikova M, Topolcan O. Pre-graduate and post-graduate education in personalized medicine in the Czech Republic: statistics, analysis and recommendations. EPMA J 2014; 5:22. [PMID: 25904992 PMCID: PMC4406177 DOI: 10.1186/1878-5085-5-22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 11/17/2014] [Indexed: 11/10/2022]
Abstract
The main goal of personalized medicine is the individualized approach to the patient's treatment. It could be achieved only by the integration of the complexity of novel findings in diverse "omics" disciplines, new methods of medical imaging, as well as implementation of reliable biomarkers into the medical care. The implementation of personalized medicine into clinical practice is dependent on the adaptation of pre-graduate and post-graduate medical education to these principles. The situation in the education of personalized medicine in the Czech Republic is analyzed together with novel educational tools that are currently established in our country. The EPMA representatives in the Czech Republic in cooperation with the working group of professionals at the Faculty of Medicine in Pilsen, Charles University in Prague have implemented the survey of personalized medicine awareness among students of Faculty of Medicine in Pilsen-the "Personalized Medicine Questionnaire". The results showed lacking knowledge of personalized medicine principles and students' will of education in this domain. Therefore, several educational activities addressed particularly to medical students and young physicians were realized at our facility with very positive evaluation. These educational activities (conferences, workshops, seminars, e-learning and special courses in personalized medicine (PM)) will be a part of pre-graduate and post-graduate medical education, will be extended to other medical faculties in our country. The "Summer School of Personalized Medicine in Plzen 2015" will be organized at the Faculty of Medicine and Faculty Hospital in Pilsen as the first event on this topic in the Czech Republic.
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Affiliation(s)
- Jiri Polivka
- />Department of Histology and Embryology, Faculty of Medicine in Pilsen, Charles University in Prague, Husova 3, Pilsen, 301 66 Czech Republic
- />Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Husova 3, Pilsen, 301 66 Czech Republic
| | - Jiri Polivka
- />Department of Neurology, Faculty of Medicine in Pilsen, Charles University in Prague and Faculty Hospital in Pilsen, alej Svobody 80, Pilsen, 304 60 Czech Republic
| | - Marie Karlikova
- />Faculty Hospital in Pilsen, Central Immunoanalytical Laboratory, alej Svobody 80, Pilsen, 304 60 Czech Republic
| | - Ondrej Topolcan
- />Faculty Hospital in Pilsen, Central Immunoanalytical Laboratory, alej Svobody 80, Pilsen, 304 60 Czech Republic
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Cosgrove L, Shaughnessy AF, Wheeler EE, Krimsky S, Peters SM, Freeman-Coppadge DJ, Lexchin JR. From caveat emptor to caveat venditor: time to stop the influence of money on practice guideline development. J Eval Clin Pract 2014; 20:809-12. [PMID: 25327453 DOI: 10.1111/jep.12244] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Lisa Cosgrove
- University of Massachusetts Boston, Boston, MA, USA; Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA, USA
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Loughlin M, Bluhm R, Fuller J, Buetow S, Upshur REG, Borgerson K, Goldenberg MJ, Kingma E. Philosophy, medicine and health care - where we have come from and where we are going. J Eval Clin Pract 2014; 20:902-7. [PMID: 25644615 DOI: 10.1111/jep.12275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2014] [Indexed: 12/21/2022]
Affiliation(s)
- Michael Loughlin
- Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK
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Tumilty E, Walker S, Tumilty S. Tainting by numbers – how the disadvantaged become invisible within evidence-based medicine. PHYSICAL THERAPY REVIEWS 2014. [DOI: 10.1179/1743288x14y.0000000152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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25
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Building capacities of elected national representatives to interpret and to use evidence for health-related policy decisions: a case study from Botswana. J Public Health Policy 2014; 35:475-88. [PMID: 25008240 DOI: 10.1057/jphp.2014.30] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Elected national representatives make decisions to fund health programmes, but may lack skills to interpret evidence on health-related topics. In 2011, we surveyed the 61 members of Botswana's Parliament about their use of epidemiological evidence, then provided two half-days of training about using evidence. We included the importance of counter-factual evidence, the number needed to treat, and unit costs of interventions. A further session in 2012 covered evidence about the HIV epidemic in Botswana and planning the best mix of interventions to reduce new HIV infections. The 27 respondents reported they lacked good quality, timely evidence, and had difficulty interpreting and using evidence. Thirty-six, including seven ministers, attended one or both trainings. They participated actively and their evaluation was positive. Our experience in Botswana could potentially be extended to other countries in the region to support evidence-based efforts to tackle the HIV epidemic.
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Rafe V, Hajvali M. A reliable architectural style for designing pervasive healthcare systems. J Med Syst 2014; 38:86. [PMID: 24994511 DOI: 10.1007/s10916-014-0086-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
Abstract
The evolution of wireless communication technologies opened the way to the definition of innovative e-Health systems aimed at providing a continuous and remote support to patients and new instruments to improve the workflow of the medical personnel. Nowadays, pervasive healthcare systems are a major step in this regard. The safety-critical systems on one hand and their failure in communication (i.e. sending and receiving messages) in other hand may lead to disaster results in the systems. Moreover, the need for high quality services in such systems, and the access to various types of Quality of Services such as reliability in software development has been increasing in the past years. In this paper, firstly we extend the core meta-model of the previously designed style for designing the structures of such systems in order to reach a high level of reliability in messaging. Secondly, their configuration mechanisms in controlling the communicative errors will be modeled using graph transformation rules. Finally, the correctness of the model is analyzed by model checking techniques. The results of the analysis show its high reliability.
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Affiliation(s)
- Vahid Rafe
- Department of Computer Engineering, Faculty of Engineering, Arak University, Arak, 38156-8-8349, Iran,
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Abbey H, Esteves J, Vogel S, Tyreman S. Assessing criticality in student research reports: Preliminary results from a new educational card sorting activity. INT J OSTEOPATH MED 2014. [DOI: 10.1016/j.ijosm.2013.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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28
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Cosgrove L, Bursztajn HJ, Erlich DR, Wheeler EE, Shaughnessy AF. Conflicts of interest and the quality of recommendations in clinical guidelines. J Eval Clin Pract 2013; 19:674-81. [PMID: 23731207 DOI: 10.1111/jep.12016] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is increasing concern that conflicts of interest affect the development process of clinical practice guidelines. We evaluated The American Psychiatric Association's Practice Guideline for the Treatment of Patients with Major Depressive Disorder to determine the existence of financial and intellectual conflicts of interest and examine their possible effects. We selected this guideline because of its influence on clinical practice and because this guideline recommends pharmacotherapy for all levels of depression, despite controversies over the evidence base. METHODS AND FINDINGS We determined the number and type of financial conflicts of interest for members of the guideline development group as well as for the independent panel charged with mitigating any effect of these conflicts. We also quantified the potential for intellectual conflicts of interest. We examined the quality of references used to support recommendations, as well as the degree of congruence between the research results and the recommendations. Fewer than half (44.4%) of the studies supporting the recommendations met criteria for high quality. Over one-third (34.2%) of the cited research did not study outpatients with major depressive disorder, and 17.2% did not measure clinically relevant results. One-fifth (19.7%) of the references were not congruent with the recommendations. Financial ties to industry were disclosed by all members (100%) of the guideline development committee with members reporting a mean 20.5 relationships (range 9-33). The majority of the committee participated on pharmaceutical companies' speakers' bureaus. Members of the independent panel that reviewed the guidelines for bias had undeclared financial relationships. As a marker of intellectual conflict of interest, 9.1% of all cited research and 13% of references supporting the recommendations were co-authored by the six guideline developers. CONCLUSIONS The prevalence of conflicts of interest among panel members was high. The quality of the evidence cited raises questions about the validity of the recommendations. Attention to the quality of cited studies and to the risk of bias resulting from conflicts of interest should be a priority for guideline development groups.
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Affiliation(s)
- Lisa Cosgrove
- The Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA, USA.
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29
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Loughlin M, Bluhm R, Stoyanov DS, Buetow S, Upshur REG, Borgerson K, Goldenberg MJ, Kingma E. Explanation, understanding, objectivity and experience. J Eval Clin Pract 2013; 19:415-21. [PMID: 23692221 DOI: 10.1111/jep.12060] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2013] [Indexed: 01/30/2023]
Affiliation(s)
| | - Robyn Bluhm
- Department of Philosophy and Religious Studies; Old Dominion University; Norfolk Virginia USA
| | - Drozdstoj S. Stoyanov
- Department of Psychiatry and Medical Psychology; MUP & Vice Chair Philosophy SIG; Royal College of Psychiatrists; London UK
- Center for Philosophy of Science; University of Pittsburgh; Pittsburgh Pennsylvania USA
| | - Stephen Buetow
- Department of General Practice; University of Auckland; Auckland New Zealand
| | - Ross E. G. Upshur
- University of Toronto Joint Centre for Bioethics; Toronto Ontario Canada
| | - Kirstin Borgerson
- Department of Philosophy; Dalhousie University; Halifax Nova Scotia Canada
| | | | - Elselijn Kingma
- King's College Centre for Humanities and Health; Department of Philosophy; King's College London; London UK
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Lhussier M, Eaton S, Forster N, Thomas M, Roberts S, Carr SM. Care planning for long-term conditions – a concept mapping. Health Expect 2013; 18:605-24. [PMID: 23565881 DOI: 10.1111/hex.12063] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2013] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE This article focuses on approaches within clinical practice that seek to actively involve patients with long-term conditions (LTCs) and how professionals may understand and implement them. Personalized care planning is one such approach, but its current lack of conceptual clarity might have impeded its widespread implementation to date. A variety of overlapping concepts coexist in the literature, which have the potential to impair both clinical and research agendas. The aim of this article is therefore to explore the meaning of the concept of care planning in relation to other overlapping concepts and how this translates into clinical practice implementation. METHODS Searches were conducted in the Cochrane database for systematic reviews, CINHAL and MEDLINE. A staged approach to conducting the concept mapping was undertaken, by (i) an examination of the literature on care planning in LTCs; (ii) identification of related terms; (iii) locating reviews of those terms. Retrieved articles were subjected to a content analysis, which formed the basis of our concept maps. (iv) We then appraised these against knowledge and experience of the implementation of care planning in clinical practice. RESULTS AND CONCLUSIONS Thirteen articles were retrieved, in which the core importance of patient-centredness, shared decision making and self-management was highlighted. Literature searches on these terms retrieved a further 24 articles. Our concept mapping exercise shows that whilst there are common themes across the concepts, the differences between them reflect the context and intended outcomes within clinical practice. We argue that this clarification exercise will allow for further development of both research and clinical implementation agendas.
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Affiliation(s)
- Monique Lhussier
- Northumbria University, Newcastle Upon Tyne, UK.,FUSE, UKCRC Centre for Translational Research in Public Health, Newcastle Upon Tyne, UK
| | - Simon Eaton
- Year of Care Partnerships, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Mathew Thomas
- NHS County Durham and Darlington, Durham, UK.,NHS North East, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Sue Roberts
- Year of Care Partnerships, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Susan M Carr
- Northumbria University, Newcastle Upon Tyne, UK.,FUSE, UKCRC Centre for Translational Research in Public Health, Newcastle Upon Tyne, UK
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Loughlin M, Bluhm R, Buetow S, Upshur REG, Goldenberg MJ, Borgerson K, Entwistle V, Kingma E. Reason and value: making reasoning fit for practice. J Eval Clin Pract 2012; 18:929-37. [PMID: 22994987 DOI: 10.1111/j.1365-2753.2012.01896.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Michael Loughlin
- Department of Interdisciplinary Studies; MMU Cheshire; Crewe; UK
| | - Robyn Bluhm
- Department of Philosophy and Religious Studies; Old Dominion University; Norfolk; VA; USA
| | - Stephen Buetow
- Department of General Practice; University of Auckland; Auckland; New Zealand
| | - Ross E. G. Upshur
- University of Toronto Joint Centre for Bioethics; Toronto; ON; Canada
| | | | | | - Vikki Entwistle
- Social Dimensions of Health Institute; University of Dundee; Dundee; UK
| | - Elselijn Kingma
- King's College Centre for Humanities and Health/Department of Philosophy; King's College London; London; UK
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Kerry R, Eriksen TE, Lie SAN, Mumford SD, Anjum RL. Causation and evidence-based practice: an ontological review. J Eval Clin Pract 2012; 18:1006-12. [PMID: 22994999 DOI: 10.1111/j.1365-2753.2012.01908.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This paper explores the nature of causation within the framework of evidence-based practice (EBP) for health care. The aims of the paper were first to define and evaluate how causation is presently accounted for in EBP; second, to present an alternative causal account by which health care can develop in both its clinical application and its scientific research activity. The paper was premised on the idea that causation underlies medical and health care practices and impacts on the way we understand health science research and daily clinical practice. The question of what causation is should therefore be of utmost relevance for all concerned with the science, philosophy and progress of EBP. We propose that the way causation is thought of in contemporaneous health care is exposed by evidential frameworks, which categorize research methods on their epistemological strengths. It is then suggested that the current account of causation is limited in respect of both the functionality of EBP, and its inherent scientific processes. An alternative ontology of causation is provided, which has its roots in dispositionalism. Here, causes are not seen as regular events necessitating an effect, but rather phenomena that are highly complex, context-sensitive and that tend towards an effect. We see this as a better account of causation for evidence-based health care.
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Affiliation(s)
- Roger Kerry
- Department of Philosophy, University of Nottingham, Nottingham, UK.
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Harvey A, Brand A, Holgate ST, Kristiansen LV, Lehrach H, Palotie A, Prainsack B. The future of technologies for personalised medicine. N Biotechnol 2012; 29:625-33. [PMID: 23091837 DOI: 10.1016/j.nbt.2012.03.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Personalised medicine promises prediction, prevention and treatment of illness that is targeted to individuals’ needs. New technologies for detailed biological profiling of individuals at the molecular level have been crucial in initiating the move to personalised medicine; further novel technologies will be necessary if the vision is to become a reality. We will need to develop new technologies to collect and analyse data in a way that is not just linear but integrated (understanding system level functioning) and dynamic (understanding system in flux). Key factors in the development of technologies for personalised medicine are standardisation, integration and harmonisation. For example, the tools and processes for data collection and analysis must be standardised across research sites. Research activity at different sites must be integrated to maximise synergies, and scientific research must be integrated with healthcare to ensure effective translation. There must also be harmonisation between scientific practices in different research sites, between science and healthcare and between science, healthcare and wider society, including the ethical and regulatory frameworks, the prevailing political and cultural ethos and the expectations of patients/citizens.
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Bogdan-Lovis E, Fleck L, Barry HC. It's NOT FAIR! Or is it? The promise and the tyranny of evidence-based performance assessment. THEORETICAL MEDICINE AND BIOETHICS 2012; 33:293-311. [PMID: 22825592 DOI: 10.1007/s11017-012-9228-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Evidence-based medicine (EBM), by its ability to decrease irrational variations in health care, was expected to improve healthcare quality and outcomes. The utility of EBM principles evolved from individual clinical decision-making to wider foundational clinical practice guideline applications, cost containment measures, and clinical quality performance measures. At this evolutionary juncture one can ask the following questions. Given the time-limited exigencies of daily clinical practice, is it tenable for clinicians to follow guidelines? Whose or what interests are served by applying performance assessments? Does such application improve medical care quality? What happens when the best interests of vested parties conflict? Mindful of the constellation of socially and clinically relevant variables influencing health outcomes, is it fair to apply evidence-based performance assessment tools to judge the merits of clinical decision-making? Finally, is it fair and just to incentivize clinicians in ways that might sway clinical judgment? To address these questions, we consider various clinical applications of performance assessment strategies, examining what performance measures purport to measure, how they are measured and whether such applications demonstrably improve quality. With attention to the merits and frailties associated with such applications, we devise and defend criteria that distinguish between justice-sustaining and justice-threatening performance-based clinical protocols.
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Affiliation(s)
- Elizabeth Bogdan-Lovis
- Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Fee Hall, 965 Fee Road, Room C222, East Lansing, MI 48824, USA.
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Komesaroff PA, Moore A, Kerridge IH. Medicine and science must oppose intolerance and censorship. Med J Aust 2012; 197:82-3. [DOI: 10.5694/mja12.10500] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Amber Moore
- Department of Medicine, Monash University, Melbourne, VIC
- Three Lanterns, Melbourne, VIC
| | - Ian H Kerridge
- Royal North Shore Hospital, Sydney, NSW
- Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW
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Loughlin M, Lewith G, Falkenberg T. Science, Practice and Mythology: A Definition and Examination of the Implications of Scientism in Medicine. HEALTH CARE ANALYSIS 2012; 21:130-45. [DOI: 10.1007/s10728-012-0211-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Christie J, Hamill C, Power J. How can we maximize nursing students’ learning about research evidence and utilization in undergraduate, preregistration programmes? A discussion paper. J Adv Nurs 2012; 68:2789-801. [DOI: 10.1111/j.1365-2648.2012.05994.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Evidence-based medicine is a method of healthcare decision-making that intends to combine the most reliable scientific information with individual expertise and patient preferences in order to offer the optimal diagnostic and therapeutic option for the patient. In recent years, the term personalized medicine has been introduced to represent an approach considering differences among individual patients. In modern medicine the most important sources of evidence are clinical trials using epidemiological methods, and molecular biological and genetic methods characterizing individual patients. Responses to a certain therapeutic intervention differ among patients for several reasons. Identifying benefits and harms of an intervention can be handled by two approaches. The first is a statistical approach using the rule of large numbers, resulting in statistically meaningful conclusions. The other approach is personalized: the conclusions are valid for individual patients or subgroups identified by well-defined markers. Whether the evidence is statistical deriving from a large number of clinical observations or personalized based on molecular studies - it should be scientifically sound to apply in clinical practice. Confronting evidence-based medicine with personalized medicine would be justified only if the former is misinterpreted and restricted only to the use of randomized trials and their systematic reviews. The practice of personalized medicine is also based on evidence, and in many instances evidence from molecular research is also statistical in nature. Regarding healthcare decision about an individual patient, whether using evidence from randomized trials or from molecular studies of biomarkers, we have to base our decisions on reliable, good quality evidence. Evidence from molecular and genetic medicine thus improves the armament of evidence-based medicine, and this upgrade yields a more reliable support for our decisions in everyday practice.
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Affiliation(s)
- Daniel Bereczki
- Deparment of Neurology, Semmelweis University, Budapest, Balassa u. 6, H-1083, Hungary.
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40
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Affiliation(s)
- Irene Ilott
- Sheffield Teaching Hospitals NHS Foundation Trust; 11 Broomfield Road Sheffield S10 2SE UK
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41
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St Stoyanov D, Machamer PK, Schaffner KF. Rendering clinical psychology an evidence-based scientific discipline: a case study. J Eval Clin Pract 2012; 18:149-54. [PMID: 22098092 DOI: 10.1111/j.1365-2753.2011.01795.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Both modern neuroscience and clinical psychology taken as separate fields have failed to reveal the explanatory mechanisms underlying mental disorders. The evidence acquired inside the mono-disciplinary matrices of neurobiology, clinical psychology and psychopathology are deeply insufficient in terms of their validity, reliability and utility. Further, no effective trans-disciplinary connections have been developed between them. ARGUMENT In this context, our case study aims at illustrating some specific facets of clinical psychology as a crucial discipline for explaining and understanding mental disorder. The methods employed in clinical psychology are scrutinized using the exemplar case of the Minnesota Multiphasic Personality Inventory (MMPI). We demonstrate that a clinical interview and a clinical psychological rating scale consist of the same kind of cognitive content. The provisional difference can be described in terms of its having two comparable complementary cognitive structures. The test is composed of self-evaluation reports (items) formulated as questions or statements. The psychopathological structured interview is formulated in terms of subjective experience indicated as symptoms (these are self-reports recorded by the physician), complemented with the so-called 'signs' or the presumably 'objective' observations of the overt behaviours of the patient. However, the cognitive content of clinical judgment is beyond any doubt as subjective as the narrative of the patient. None of the components of the structured psychopathological interview is independent of the inter-subjective system created in the situation of clinical assessment. CONCLUSION Therefore, the protocols from various clinicians that serve to sustain the reliability claim of the 'scientific' Diagnostic Statistical Manual of Mental Disorders cannot be regarded as independent measurements of the cognitive content and value of the psychological rating scales or vice versa.
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Aas RW, Alexanderson K. Challenging Evidence-based Decision-making: A Hypothetical Case Study about Return to Work. Occup Ther Int 2011; 19:28-44. [DOI: 10.1002/oti.326] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 09/10/2011] [Accepted: 09/14/2011] [Indexed: 12/14/2022] Open
Affiliation(s)
- Randi W. Aas
- PreSenter; International Research Institute of Stavanger (IRIS); Stavanger Norway
- Division of Insurance Medicine, Department of Clinical Neuroscience; Karolinska Institutet; Stockholm Sweden
- PreSenter, Faculty of Health Sciences; Institute of Occupational Therapy, Oslo and Akershus University College; Oslo Norway
| | - Kristina Alexanderson
- Division of Insurance Medicine, Department of Clinical Neuroscience; Karolinska Institutet; Stockholm Sweden
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43
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Kienle GS, Albonico HU, Fischer L, Frei-Erb M, Hamre HJ, Heusser P, Matthiessen PF, Renfer A, Kiene H. Complementary therapy systems and their integrative evaluation. Explore (NY) 2011; 7:175-87. [PMID: 21571237 DOI: 10.1016/j.explore.2011.02.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Indexed: 02/07/2023]
Abstract
Complementary and alternative medicine (CAM) is becoming an integral part of modern medicine. Complementary and alternative medicine therapy systems include natural medicinal products, nonpharmacological treatments, and counselling on health and lifestyle issues. Complementary and alternative medicine concepts are often elaborate, transcending biophysical models and employing the principles of salutogenesis. Evaluations of CAM therapy systems need to be integrative and cover the dimensions of: (1) therapeutic professionalism; (2) patient perspective and public demand; (3) conceptuality; (4) safety, effectiveness, and costs. Complex research strategies are required, which reverse the phases of conventional drug assessment. The predominant use of randomized trials would introduce structural bias and create an artificial picture. Important are evaluations of the whole system in real-world conditions, and surveys on component evaluations. Systemic CAM assessments should consist of a broad array of high-quality research methods: well-conducted randomized and nonrandomized studies, cohort studies, qualitative research, high-quality case reports and case series, studies on patient perspective, safety analyses, economic analyses, etc. Good clinical judgement, a core epistemic element of medicine based on nonstochastic principles, should also be integrated and could reflect routine patient care.
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Loughlin M, Bluhm R, Buetow S, Upshur REG, Goldenberg MJ, Borgerson K, Entwistle V. Virtue, progress and practice. J Eval Clin Pract 2011; 17:839-46. [PMID: 21951924 DOI: 10.1111/j.1365-2753.2011.01748.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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45
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Calderón C, Sola I, Rotaeche R, Marzo-Castillejo M, Louro-González A, Carrillo R, González AI, Alonso-Coello P. EBM in primary care: a qualitative multicenter study in Spain. BMC FAMILY PRACTICE 2011; 12:84. [PMID: 21827662 PMCID: PMC3166903 DOI: 10.1186/1471-2296-12-84] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 08/09/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Evidence based medicine (EBM) has made a substantial impact on primary care in Spain over the last few years. However, little research has been done into family physicians (FPs)' attitudes related to EBM. The present study investigates FPs' perceptions of EBM in the primary care context. METHODS This study used qualitative methodology. Information was obtained from 8 focus groups composed of 67 FPs from 47 health centers in 4 autonomous regions in Spain. Intentional sampling considered participants' previous education in EBM, and their experience as tutors in family medicine or working groups' members of the Spanish Society of Family Practice. Sociological discourse analysis was used with the support of the MAXqda software. Results were validated by means of triangulation among researchers and contrast with participants. RESULTS Findings were grouped into three main areas: 1) The tug-of-war between the "science" of EBM and "experience" in the search for good clinical practice in primary care; 2) The development of EBM sensemaking as a reaction to contextual factors and interests; 3) The paradox of doubt and trust in the new EBM experts.The meaning of EBM was dynamically constructed within the primary care context. FPs did not consider good clinical practice was limited to the vision of science that EBM represents. Its use appeared to be conditioned by several factors that transcended the common concept of barriers. Along with concerns about its objectivity, participants showed a tendency to see EBM as the use of simplified guidelines developed by EBM experts. CONCLUSIONS The identification of science with EBM and its recognition as a useful but insufficient tool for the good clinical practice requires rethinking new meanings of evidence within the primary care reality. Beyond the barriers related to accessing and putting into practice the EBM, its reactive use can determine FPs' questions and EBM development in a direction not always centred on patients' needs. The questioning of experts' authority as a pillar of EBM could be challenged by the emergence of new kinds of EBM texts and experts to believe in.
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Affiliation(s)
| | - Iván Sola
- Iberoamerican Cochrane Center, Hospital Sant Pau, Sant Antoni Maria Claret 171, Barcelona, Spain
| | | | | | | | - Ricard Carrillo
- EAP La Florida Sud, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Hospital Sant Pau, Sant Antoni Maria Claret 171, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
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46
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Miles A, Loughlin M. Models in the balance: evidence-based medicine versus evidence-informed individualized care. J Eval Clin Pract 2011; 17:531-6. [PMID: 21794027 DOI: 10.1111/j.1365-2753.2011.01713.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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47
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Racine L, Perron A. Unmasking the predicament of cultural voyeurism: a postcolonial analysis of international nursing placements. Nurs Inq 2011; 19:190-201. [DOI: 10.1111/j.1440-1800.2011.00555.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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48
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Mezzich J, Snaedal J, van Weel C, Heath I. Toward person-centered medicine: from disease to patient to person. ACTA ACUST UNITED AC 2011; 77:304-6. [PMID: 20506456 DOI: 10.1002/msj.20187] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Juan Mezzich
- Mount Sinai School of Medicine New York, NY, USA.
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Mezzich JE. The Geneva Conferences and the emergence of the International Network for Person-centered Medicine. J Eval Clin Pract 2011; 17:333-6. [PMID: 21114715 DOI: 10.1111/j.1365-2753.2010.01576.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The yearly Geneva Conferences on Person-centered Medicine started in May 2008 as a collaborative effort of global medical and health organizations and committed clinicians and scholars to place the whole person at the centre of medicine and health care. They were informed by the traditions of great ancient civilizations and recent developments in clinical care and public health. The process of the Geneva Conferences led to the development of the International Network for Person-centered Medicine as a non-for-profit institution aimed at organizing future editions of the Geneva Conference and building person-centred medicine as a paradigmatic repriorizing of the medical and health fields in collaboration inter alia with the World Medical Association, the World Health Organization and the World Organization of Family Doctors.
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Affiliation(s)
- Juan E Mezzich
- International Network for Person-centered Medicine, President 2005–2008, World Psychiatric Association and Mount Sinai School of Medicine, New York University, New York, USA.
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50
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Reflexiones éticas en oftalmología. REVISTA MÉDICA CLÍNICA LAS CONDES 2010. [DOI: 10.1016/s0716-8640(10)70628-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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