'All the King's horses . . .’: the problematical fate of born-again evidence-based medicine: commentary on Greenhalgh, T., Snow, R., Ryan, S., Rees, S., and Salisbury, H. (2015) six 'biases' against patients and carers in evidence-based medicine. BioMed Central Medicine, 13:200

On crowns, caravans and windmills: Commentary on an essay by Turcotte P., et al

Patient-oriented research (POR) is a trend that has emerged over several decades and is particularly prominent in Canada, the United States and the United Kingdom. It involves patient and other stakeholder participation in the planning, conduct and dissemination of biomedical and health services research and it can be seen as a form of public participation and engagement in activities that affect the lives and well-being of communities. Criticisms of POR revolve around its susceptibility to tokenistic treatment of patient participants and paternalistic dominance of the research agenda by professional researchers, academics and clinicians. This commentary addresses one such critique by situating the POR agenda within the challenges and dilemmas faced by the health-related research enterprise over the past 30 years. It will explore the interface between POR, community activism and community-based participatory research. The contextual importance of the COVID-19 pandemic experience is stressed. The commentary will particularly focus on the US-based Patient Centred Outcomes Research Institute, its origins within a movement to enhance emphasis on publicly funded comparative effectiveness research, and its more recent evolution in the direction of community empowerment in POR.

Naturopaths' mobilisation of knowledge and information in clinical practice: an international cross-sectional survey

BACKGROUND

The contemporary evidence-based practice model acknowledges the importance of patient preferences and clinician experience when applying evidence within a clinical setting. Knowledge mobilisation (KM) acknowledges the complexities of knowledge translation by recognising and respecting diversity in types of knowledge and how such diversity can influence health care and health care choices. While there has been considerable discussion on KM in health care, it has received little attention in the field of naturopathy. Despite naturopathy's widespread international use, it is unclear how naturopathic practitioners (NPs) use and share knowledge and information in clinical practice. This study examines the mobilisation of knowledge amongst NPs internationally.

METHODS

Online, international, cross-sectional survey of a self-selected sample of NPs from any country, that were either currently in clinical practice or had been in practice within the previous 12 months. The survey was administered in five languages (English, French, Portuguese, Spanish, German). Descriptive statistics were prepared for all survey items.

RESULTS

The survey was completed by 478 NPs who reported using an average of seven (median = 7, SD = 2.6) information sources to inform patient care. NPs also drew on knowledge gained through patients sharing their perspectives of living with their health condition (Always/Most of the time: 89.3%). They mostly sought knowledge about how a treatment might benefit a patient, as well as knowledge about treatment safety and a better understanding of a patient's health condition. NPs frequently reported sharing knowledge developed through consideration of the patient's unique needs (83.3%), and primarily shared knowledge by producing information for the public (72.6%) and for patients (72.2%).

CONCLUSIONS

Based on these findings, it may be argued that NPs practice knowledge mobilisation; employing multiple forms and sources of knowledge, and mobilising knowledge to - as well as from - others. Due to their active engagement in patient and community education, NPs also may be considered knowledge brokers. In the context of the growing understanding of the complexities of knowledge translation and mobilisation in contemporary health care - and particularly within the context of implementation science - this study provides novel insights into an under-researched element of health services accessed by the community.

"You can be blind because of loving them so much": the impact on owners in the United Kingdom of living with a dog with osteoarthritis

BACKGROUND

There is growing awareness that caring for a chronically ill pet may have a detrimental impact on their owner's quality of life. Companion animal orthopaedic disease has received little research interest in this context. Canine osteoarthritis is known to negatively affect the welfare of many dogs in the United Kingdom, but its consequences for their owners has not previously been described. The aim of this study was to use a qualitative methodology to explore the impacts on a dog owner that occur following their dog's diagnosis with osteoarthritis. Owners of osteoarthritic dogs based in the United Kingdom (UK) were recruited through veterinary practices to participate in semi-structured interview about life with their dog. Interviews were transcribed verbatim and thematic analysis was used to construct key themes. This publication describes the theme that focused on the impact(s) that the dog's condition had had on the life of their owner.

RESULTS

Forty owners of 35 dogs of a range of breeds and ages were interviewed. A wide range of negative impacts on the physical, mental and financial health of owners were described. Few had any prior experience of canine osteoarthritis, and owners of young dogs appeared to be particularly affected by the diagnosis. Owners detailed increasing worry over time about their pet's condition, frequently combined with a growing need to physically assist their dog. Sometimes this led them to seek information about, and purchase, adjunctive therapies and products. The dog's reduced mobility and need for medications progressively limited their own lifestyles and ability to have time away from their pet. Owners typically described a strong bond with their dog as a motivator to provide ongoing care.

CONCLUSIONS

The negative impacts on owners of caring for an osteoarthritic dog appear multi-faceted and may be sustained over many years, particularly if the dog is young at diagnosis. Owners may be highly motivated to improve their dog's mobility and to reduce the impact the condition has on their own lives, yet they may be unsure how to achieve this. Veterinary professionals should inform and support these owners as much as possible.

The multiple faces of practical wisdom in complex clinical practices: An empirical exploration

RATIONALE, AIMS, AND OBJECTIVES

In recent publications, attention has been drawn to the importance of practical wisdom in order to ensure good, individually attuned care in complex clinical practices. However, what remains insufficiently elucidated is how practical wisdom emerges in the workplace. This study aims to describe manifestations of practical wisdom in medical practices within a general hospital. It also seeks to clarify the interruptions that can be considered as triggers for the emergence of practical wisdom. Furthermore, we searched for figurations, which possibly elicit or constrain the emergence of practical wisdom.

METHODS

We used 10 thick descriptions of very distinct patient cases to carry out an explorative qualitative heuristic in-depth analysis.

RESULTS

These varied cases enabled us to describe diverse manifestations of practical wisdom; in addition, we were able to discern 10 different "interruptions" that triggered practical wisdom, and finally, we hypothesize that certain infrastructural figurations might facilitate the manifestation of practical wisdom.

CONCLUSIONS

We found that practical wisdom frequently emerged in unexpected and diverse guises in these clinical practices, although the "interruptions" that we discovered did not automatically trigger practical wisdom. We have investigated the figurations mentioned only to a limited degree. More empirical research is needed to make the philosophical concept of practical wisdom better manageable for clinical practices and to gain better understanding of the figurations that elicit or obstruct its manifestation.

From MARS to MAGIC: The remarkable journey through time and space of the Grading of Recommendations Assessment, Development and Evaluation initiative

For over 30 years, "evidence-based" clinical guidelines remained entrenched in an oversimplified, design-based, framework for rating the strength of evidence supporting clinical recommendations. The approach frequently equated the rating of evidence with that of the recommendations themselves. "Grading Recommendations Assessment, Development and Evaluation (GRADE)" has emerged as a proposed antidote to obsolete guideline methodology. GRADE sponsors and collaborators are in the process of attempting to amplify and extend the framework to encompass implementation and adaptation of guidelines, above and beyond the evaluation and rating of clinical research. Alternative schemes and models for such extensions are beginning to appear. This commentary reviews the strengths and weaknesses of GRADE with reference to other recent critiques. It considers the GRADE Working Group's "evidence-to-decision" extension of the evidence rating framework, together with proposed alternatives. It identifies pitfalls of the GRADE system's cooptation of relational processes necessary to the interpretation and uptake of recommendations that properly belong to end-users. It also identifies dangers inherent in blurring important boundaries between clinical and policy applications of guidelines. Finally, it addresses criticisms regarding the lack of a theoretical framework supporting the different facets of the GRADE approach and proposes a social constructivist orientation to clinical guideline development and use. Recommendations are offered to potential guideline developers and users regarding how to draw upon the strengths of the GRADE framework without succumbing to its pitfalls.

Valuing Healthcare Improvement: Implicit Norms, Explicit Normativity, and Human Agency

I argue that greater attention to human agency and normativity in both researching and practicing service improvement may be one strategy for enhancing improvement science, illustrating with examples from cancer screening. Improvement science tends to deliberately avoid explicit normativity, for paradigmatically coherent reasons. But there are good reasons to consider including explicit normativity in thinking about improvement. Values and moral judgements are central to social life, so an adequate account of social life must include these elements. And improvement itself is unavoidably normative: it assumes that things could and should be better than they are. I seek to show that normativity will always be implicated in the creation of evidence, the design of programs, the practice of healthcare, and in citizens' judgements about that care, and to make a case that engaging with this normativity is worthwhile.

From the EBM pyramid to the Greek temple: a new conceptual approach to Guidelines as implementation tools in mental health

Guideline methods to develop recommendations dedicate most effort around organising discovery and corroboration knowledge following the evidence-based medicine (EBM) framework. Guidelines typically use a single dimension of information, and generally discard contextual evidence and formal expert knowledge and consumer's experiences in the process. In recognition of the limitations of guidelines in complex cases, complex interventions and systems research, there has been significant effort to develop new tools, guides, resources and structures to use alongside EBM methods of guideline development. In addition to these advances, a new framework based on the philosophy of science is required. Guidelines should be defined as implementation decision support tools for improving the decision-making process in real-world practice and not only as a procedure to optimise the knowledge base of scientific discovery and corroboration. A shift from the model of the EBM pyramid of corroboration of evidence to the use of broader multi-domain perspective graphically depicted as 'Greek temple' could be considered. This model takes into account the different stages of scientific knowledge (discovery, corroboration and implementation), the sources of knowledge relevant to guideline development (experimental, observational, contextual, expert-based and experiential); their underlying inference mechanisms (deduction, induction, abduction, means-end inferences) and a more precise definition of evidence and related terms. The applicability of this broader approach is presented for the development of the Canadian Consensus Guidelines for the Primary Care of People with Developmental Disabilities.

Teaching by (bad) example: what a confused attempt to "advance" EBM reveals about its underlying problems: commentary on Jenicek, M. (2015). Do we need another discipline in medicine? From epidemiology and evidence-based medicine to cognitive medicine and medical thinking. Journal of evaluation in clinical practice, 21:1028-1034

Professor Jenicek's paper is confused in that his proposal to 'integrate' what he means by 'evidence-based scientific theory and cognitive approaches to medical thinking' actually embodies a contradiction. But, although confused, he succeeds in teaching us more about the EBM debate than those who seem keen to forge ahead without addressing the underlying epistemological problems that Jenicek brings to our attention. Fundamental questions about the relationship between evidence, knowledge and reason still require resolution if we are to see a genuine advance in this debate.