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Bernardi R, Eidlin M. Clinical Evidence, Triangulation of Perspectives and Contextualization. Part 1: The Beginning of Carla's Treatment. THE PSYCHOANALYTIC QUARTERLY 2024; 93:33-76. [PMID: 38578265 DOI: 10.1080/00332828.2024.2316218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 04/06/2024]
Abstract
We propose to critically evaluate and strengthen the level of clinical evidence in psychoanalysis, using a strategy of triangulating clinical phenomena from different perspectives and increasing contextual knowledge. Insufficient discussion of alternative hypotheses and limited contextual information are two Achilles heels of psychoanalytic case presentations. We examine the concept and quality standards of clinical evidence in psychoanalysis and related disciplines, with particular attention to the contribution of the three-level model (3-LM). We analyze the case of a patient treated with transference-focused psychotherapy (TFP), making explicit the theoretical-clinical agreements and disagreements of the authors. We discuss the strengths and limitations of triangulation and contextualization, concluding that they make clinical work and psychoanalytic writing more reliable, transparent, auditable, and replicable.
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Affiliation(s)
| | - Monica Eidlin
- Ricardo Bernardi Juan Benito Blanco 1285 Apto. 602 11 300 Montevideo Uruguay
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2
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Espay AJ, Herrup K, Daly T. Finding the falsification threshold of the toxic proteinopathy hypothesis in neurodegeneration. HANDBOOK OF CLINICAL NEUROLOGY 2023; 192:143-154. [PMID: 36796939 DOI: 10.1016/b978-0-323-85538-9.00008-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
A biomedical hypothesis is a theoretical assumption amenable to being tested in a randomized clinical trial. The main hypotheses in neurodegenerative disorders are based on the concept that proteins accumulate in an aggregated fashion and trigger toxicity. The toxic proteinopathy hypothesis posits that neurodegeneration is caused by toxicity of aggregated amyloid in Alzheimer's disease (toxic amyloid hypothesis), aggregated α-synuclein in Parkinson's disease (toxic synuclein hypothesis), and aggregated tau in progressive supranuclear palsy (toxic tau hypothesis). To date, we have accumulated 40 negative anti-amyloid randomized clinical, 2 anti-synuclein trials, and 4 anti-tau trials. These results have not prompted a major reconsideration of the toxic proteinopathy hypothesis of causality. Imperfections in trial design and execution (incorrect dosage, insensitive endpoints, too-advanced population) but not in the underlying hypotheses have prevailed as explaining the failures. We review here the evidence suggesting that the threshold of hypothesis falsifiability may be too high and advocate in favor of a minimal set of rules that facilitate the interpretation of negative clinical trials as falsifying the driving hypotheses, in particular if the desirable change in surrogate endpoints has been achieved. We propose four steps to refute a hypothesis in future-negative surrogate-backed trials and argue that for the actual rejection to take place, refutation must be accompanied by the proposal of an alternative hypothesis. The absence of alternative hypotheses may be the single greatest reason why there remains hesitancy in rejecting the toxic proteinopathy hypothesis: in the absence of alternatives, we have no clear guidance as to where to redirect or focus.
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Affiliation(s)
- Alberto J Espay
- James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, United States.
| | - Karl Herrup
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Timothy Daly
- Science Norms Democracy, Sorbonne University, Paris, France
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Merone L, Tsey K, Russell D, Daltry A, Nagle C. Evidence-Based Medicine: Feminist Criticisms and Implications for Women's Health. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2022; 3:844-849. [PMID: 36340479 PMCID: PMC9629975 DOI: 10.1089/whr.2022.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/08/2022] [Indexed: 01/25/2023]
Abstract
Evidence-based medicine (EBM) dates back to 19th-century Paris and started out as a new paradigm for practicing medicine, with the aim of replacing anecdote with high-quality evidence from positivist-style research. Despite the clear logic underpinning EBM, there have been numerous criticisms, including maintenance of an archaic view of evidence as "facts," failure to acknowledge that all research is underpinned by the beliefs of the researcher, and the simple fact that medical research has historically been androcentric and results generalized to female patients. In this essay, we discuss the criticisms of EBM, with a focus on feminist critiques based on three central feminist epistemologies: feminist empiricism, standpoint theory, and social constructivism. We argue that EBM potentially perpetuates gaps in women's health and advocate for incorporating feminist epistemologies into future medical research to garner further understanding of social influences on women's health. In addition, we argue that EBM may degrade the clinical acumen and that critical thinking should become a key component of medical school curricula.
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Affiliation(s)
- Lea Merone
- College of Healthcare Sciences, James Cook University, Townsville, Australia.,Address correspondence to: Lea Merone, FAFPHM, College of Healthcare Sciences, James Cook University, 383 Flinders Street, Townsville, Queensland 4810, Australia,
| | - Komla Tsey
- College of Arts, Society and Education, James Cook University, Smithfield, Australia
| | | | - Andrew Daltry
- Cairns and Hinterland Hospital and Health Service, Cairns, Australia
| | - Cate Nagle
- College of Healthcare Sciences, James Cook University, Townsville, Australia
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4
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Borghmans F. The radical and requisite openness of viable systems: Implications for healthcare strategy and practice. J Eval Clin Pract 2022; 28:324-331. [PMID: 33977559 DOI: 10.1111/jep.13576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/18/2021] [Indexed: 11/29/2022]
Abstract
This paper addresses an ontological question about the nature of health and challenges some underpinning assumptions in western healthcare. In its analysis, health in its various statuses, is framed as a naturally occurring complex adaptive system made up of dynamically interacting subsystems that include the physiological, psychological, and social realms. Furthermore, openness in complex systems such as health, is necessary for the exchange of energy, information, and resources. Yet, within healthcare much effort is invested in constraining systems' behaviours, whether they be systems of knowledge, health, healthcare, and more. This paper draws on the complexity sciences and Levinasian philosophy to explicate the essential role of system openness in individual, population, and systemic viability. It highlights holism to be "not whole-ism", and system openness to be, not just a reality, but a critical feature of viability. Hence requisite openness is advocated as essential to efficacious and ethical healthcare practice and strategy, and vital for health.
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Affiliation(s)
- Felice Borghmans
- Faculty of Education, Monash University, Wellington Road, Clayton, Victoria, 3800, Australia
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Kafaee M, Taqavi M. The Value of 'Traditionality': The Epistemological and Ethical Significance of Non-western Alternatives in Science. SCIENCE AND ENGINEERING ETHICS 2021; 27:6. [PMID: 33532937 DOI: 10.1007/s11948-021-00279-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 12/21/2020] [Indexed: 06/12/2023]
Abstract
After a brief review of the relationship between science and value, this paper introduces the value of 'traditionality' as a value in the pure and applied sciences. Along with other recognized values, this value can also contribute to formulating hypotheses and determining theories. There are three reasons for legitimizing the internal role of this value in science: first, this value can contribute to scientific progress by presenting more diverse hypotheses; second, the value of external consistency in science entails this value; and third, this value helps to eliminate some of the adverse social and cultural effects of Western science in non-Western societies. 'Traditionality' is an extrinsic epistemic value, according to the first two reasons, and at the same time, is an ethical value, according to the last reason. Also, the ethics of belief is adopted to further confirm the ethical role of this value. Finally, this paper discusses three potential criticisms that can be levelled against this idea and responds to each of them.
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Affiliation(s)
- Mahdi Kafaee
- Faculty of Electrical Engineering, Shahrood University of Technology, PO Box 3619995161, Shahrood, Iran.
| | - Mostafa Taqavi
- Department of Philosophy of Science, Sharif University of Technology, Tehran, Iran
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6
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Tebala GD. The Emperor's New Clothes: a Critical Appraisal of Evidence-based Medicine. Int J Med Sci 2018; 15:1397-1405. [PMID: 30275768 PMCID: PMC6158662 DOI: 10.7150/ijms.25869] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/27/2018] [Indexed: 12/20/2022] Open
Abstract
Evidence-Based Medicine (EBM) is the way we are expected to deliver our healthcare in the 21st century. It has been described as the integration of information from best available evidence with the doctor's experience and the patient's point of view. Unfortunately, the original meaning of EBM has been lost and the worldwide medical community has shifted the paradigm to Guidelines-Based Medicine, that has displaced the figures of the doctor and the patient from the decision-making process and relegated them to mere executor and final target of decisions taken by someone else. Problems related to the reliability of evidence and to the way guidelines are constructed, implemented and followed are discussed in detail. It is mandatory that the whole medical community takes responsibility and tries to reverse this apparently inexorable process so to re-establish a proper evidence-based care, where patients and their healing relation with practitioners are at the centre and where doctors are able to critically evaluate the available evidence and use it in light of their personal experience and knowledge.
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Affiliation(s)
- Giovanni D. Tebala
- East Kent Hospitals University, William Harvey Hospital, Ashford, Kent, United Kingdom
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Chin-Yee B, Upshur R. Clinical judgement in the era of big data and predictive analytics. J Eval Clin Pract 2018; 24:638-645. [PMID: 29237237 DOI: 10.1111/jep.12852] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/25/2017] [Accepted: 10/27/2017] [Indexed: 12/18/2022]
Abstract
Clinical judgement is a central and longstanding issue in the philosophy of medicine which has generated significant interest over the past few decades. In this article, we explore different approaches to clinical judgement articulated in the literature, focusing in particular on data-driven, mathematical approaches which we contrast with narrative, virtue-based approaches to clinical reasoning. We discuss the tension between these different clinical epistemologies and further explore the implications of big data and machine learning for a philosophy of clinical judgement. We argue for a pluralistic, integrative approach, and demonstrate how narrative, virtue-based clinical reasoning will remain indispensable in an era of big data and predictive analytics.
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Affiliation(s)
| | - Ross Upshur
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Affiliation(s)
| | - Wendy A. Hall
- School of Nursing; University of British Columbia; Vancouver BC Canada
| | - Sally E. Thorne
- School of Nursing; University of British Columbia; Vancouver BC Canada
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9
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Chin-Yee IH, Chin-Yee BH, Pereira A. Clinical trials and the age of blood: ABLE but still wanting. Transfus Med 2015; 25:349-50. [DOI: 10.1111/tme.12252] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 08/31/2015] [Indexed: 11/27/2022]
Affiliation(s)
- I. H. Chin-Yee
- Division of Hematology, Department of Medicine, Schulich School of Medicine; Western University; London Canada
| | - B. H. Chin-Yee
- Faculty of Medicine; University of Toronto; Toronto Canada
| | - A. Pereira
- Service of Hemotherapy and Hemostasis; Hospital Clínic; Barcelona Spain
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10
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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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