1
|
Mugerauer R. Professional judgement in clinical practice (part 3): A better alternative to strong evidence-based medicine. J Eval Clin Pract 2021; 27:612-623. [PMID: 33274580 DOI: 10.1111/jep.13512] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 01/10/2023]
Abstract
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.
Collapse
Affiliation(s)
- Robert Mugerauer
- College of Built Environments, University of Washington, Seattle, Washington, USA
| |
Collapse
|
2
|
Mugerauer R. Professional judgement in clinical practice (part 2): knowledge into practice. J Eval Clin Pract 2021; 27:603-611. [PMID: 33241613 DOI: 10.1111/jep.13514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 12/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Robert Mugerauer
- College of Built Environments, University of Washington, Seattle, Washington, USA
| |
Collapse
|
3
|
Mugerauer R. Professional judgement in clinical practice (part 1): Recovering original, moderate evidence-based health care. J Eval Clin Pract 2021; 27:592-602. [PMID: 33241623 DOI: 10.1111/jep.13513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022]
Abstract
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.
Collapse
Affiliation(s)
- Robert Mugerauer
- College of Built Environments, University of Washington, Seattle, Washington, USA
| |
Collapse
|
4
|
Moosavi A, Sadeghpour A, Azami-Aghdash S, Derakhshani N, Mohseni M, Jafarzadeh D, Rezapour A. Evidence-based medicine among health-care workers in hospitals in Iran: A nationwide survey. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2020; 9:365. [PMID: 33575401 PMCID: PMC7871975 DOI: 10.4103/jehp.jehp_335_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/25/2020] [Indexed: 05/18/2023]
Abstract
BACKGROUND Evidence-based medicine (EBM) plays an important and dominant role in promoting effective decision-making in the health system. This study was aimed to evaluate the EBM performance among health-care workers (HCWs) in hospitals in Iran. METHODS In this study (a cross-sectional study), participants were 2800 HCWs in hospitals. A researcher-made questionnaire was designed, and judgments of 10 experts were used for the improvement of content validity. The reliability of the questionnaire was assessed by the test-retest method (α = 0.85). Data were analyzed using the descriptive statistics, t-test, and one-way ANOVA, in SPSS.16 software. RESULTS Eventually, 1524 questionnaires were completed (response rate: 54.4%). The results of the study show that 62%of participants have not accessed scientific journals, 52% of them have difficulties using the Internet at work, guidelines were not reachable for 76% of them, and about 80% have not access to databases. About 39% of participants were not well informed about databases of EBM, and 15.8% of them were immensely knowledgeable about EBM terminology. The most important problems to increase HCWs information about EBM include research methodology- related problems, lack of resources and motivation, and coordination problems. The most prominent facilitators include: providing training courses in EBM and increased facilities. Only work experience showed a significant correlation with barriers and facilitators, and gender revealed a significant correlation with barriers (P < 0.05). CONCLUSION It seems that prioritizing the increased access to information resources and databases, considering the research skills of the HCWs, extending the opportunities and increasing the facilities such as workforce, equipment, physical environment, and accessibility can have a great impact on the improvement of the activities associated with EBM.
Collapse
Affiliation(s)
- Ahmad Moosavi
- Department of Health and Community Medicine, Dezful University of Medical Sciences, Dezful, Iran
| | - Alireza Sadeghpour
- Department of Orthopedic Surgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saber Azami-Aghdash
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Naser Derakhshani
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mohseni
- Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Dariush Jafarzadeh
- Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
- Address for correspondence: Dr. Aziz Rezapour, Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran. E-mail:
| |
Collapse
|
5
|
|
6
|
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
| |
Collapse
|
7
|
Fernandez A, Sturmberg J, Lukersmith S, Madden R, Torkfar G, Colagiuri R, Salvador-Carulla L. Evidence-based medicine: is it a bridge too far? Health Res Policy Syst 2015; 13:66. [PMID: 26546273 PMCID: PMC4636779 DOI: 10.1186/s12961-015-0057-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 10/29/2015] [Indexed: 01/28/2023] Open
Abstract
AIMS This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science. RESULTS The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer's ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients' values and the context. CONCLUSION EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.
Collapse
Affiliation(s)
- Ana Fernandez
- Brain and Mind Centre, Faculty of Health Sciences, The University of Sydney, 94 Mallett Street, Camperdown, NSW, 2050, Australia.
| | - Joachim Sturmberg
- Discipline of General Practice, School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia.
| | - Sue Lukersmith
- Centre for Disability Research and Policy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
| | - Rosamond Madden
- Centre for Disability Research and Policy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
| | - Ghazal Torkfar
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia.
| | - Ruth Colagiuri
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia.
| | - Luis Salvador-Carulla
- Centre for Disability Research and Policy-Brain and Mind Centre, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
| |
Collapse
|
8
|
Abu Farha R, Alefishat E, Suyagh M, Elayeh E, Mayyas A. Evidence-based medicine use in pharmacy practice: a cross-sectional survey. J Eval Clin Pract 2014; 20:786-92. [PMID: 25040154 DOI: 10.1111/jep.12212] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2014] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES This study aimed to evaluate the awareness, attitude, knowledge and use of evidence-based medicine (EBM) among pharmacists in Jordan. METHODS A cross-sectional self-reported survey was conducted on 122 pharmacists (both hospital and community) who were asked to fill a validated structured questionnaire. RESULTS The participants showed a positive attitude towards EBM; more than 80% thought that EBM improves patient care, improves quick knowledge update, helps to unify the quality of care provided, is a good educational tool and a convenient source of advice. But despite this positive attitude, pharmacists showed partial understanding of the technical terms used in EBM; also they relied on their own judgment, medical representatives and standard textbooks in making their decision, resources that can no longer be considered sufficiently updated and/or evidence based. Patient overload, lack of personal time and limited access to EBM sources were the most commonly identified barrier to practicing EBM. Also this study suggest that pharmacist's experience is negatively associated with EBM knowledge score (Spearman's rho value -0.187, P-value 0.04). CONCLUSIONS In spite of the positive attitude towards EBM, this study showed numerous personal and institutional barriers towards implementing EBM in Jordan, which necessitate immediate action by all health care decision makers to formulate a national plan to overcome such barriers, and to further investigate the evidence that teaching, learning and daily application of EBM in practice can improve the quality of care and reduce the cost.
Collapse
Affiliation(s)
- Rana Abu Farha
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman, Jordan
| | | | | | | | | |
Collapse
|
9
|
Seshia SS, Makhinson M, Young GB. Evidence-informed person-centred health care (part II): are 'cognitive biases plus' underlying the EBM paradigm responsible for undermining the quality of evidence? J Eval Clin Pract 2014; 20:748-58. [PMID: 25494630 DOI: 10.1111/jep.12291] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2014] [Indexed: 12/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Shashi S Seshia
- Department of Pediatrics, Division of Pediatric Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | | |
Collapse
|
10
|
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.
Collapse
|
11
|
Charles C, Gafni A, Freeman E. The evidence-based medicine model of clinical practice: scientific teaching or belief-based preaching? J Eval Clin Pract 2011; 17:597-605. [PMID: 21087367 DOI: 10.1111/j.1365-2753.2010.01562.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE Evidence-based medicine (EBM) is commonly advocated as a 'gold standard' of clinical practice. A prominent definition of EBM is: the integration of best research evidence with clinical expertise and patient values. Over time, various versions of a conceptual model or framework for implementing EBM (i.e. how to practice EBM) have been developed. AIMS AND OBJECTIVES This paper (i) traces the evolution of the different versions of the conceptual model; (ii) tries to make explicit the underlying goals, assumptions and logic of the various versions by exploring the definitions and meaning of the components identified in each model, and the methods suggested for integrating these into clinical practice; and (iii) offers an analytic critique of the various model iterations. METHODS A literature review was undertaken to identify, summarize, and compare the content of articles and books discussing EBM as a conceptual model to guide physicians in clinical practice. RESULTS Our findings suggest that the EBM model of clinical practice, as it has evolved over time, is largely belief-based, because it is lacking in empirical evidence and theoretical support. The model is not well developed and articulated in terms of defining model components, justifying their inclusion and suggesting ways to integrate these in clinical practice. CONCLUSION These findings are significant because without a model that clearly defines what constitutes an EBM approach to clinical practice we cannot (i) consistently teach clinicians how to do it and (ii) evaluate whether it is being done.
Collapse
Affiliation(s)
- Cathy Charles
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
| | | | | |
Collapse
|
12
|
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]
|
13
|
Miles A. On a medicine of the whole person: away from scientistic reductionism and towards the embrace of the complex in clinical practice. J Eval Clin Pract 2009; 15:941-9. [PMID: 20367688 DOI: 10.1111/j.1365-2753.2009.01354.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Andrew Miles
- Journal of Evaluation in Clinical Practice, National Director, UK Key Advances in Clinical Practice Series, Medical School at the University of Buckingham (London Campus), London, UK.
| |
Collapse
|
14
|
Miles A. On the interface between science, medicine, faith and values in the individualization of clinical practice: a review and analysis of 'Medicine of the Person' Cox, J., Campbell, A. V. & Fulford, K. W. M., eds (2007). J Eval Clin Pract 2009; 15:1000-24. [PMID: 20367700 DOI: 10.1111/j.1365-2753.2009.01351.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Andrew Miles
- Journal of Evaluation in Clinical Practice and National Director, UK Key Advances in Clinical Practice Series, Medical School at the University of Buckingham (London Campus), London, UK.
| |
Collapse
|
15
|
|