The judgements that evidence‐based medicine adopts

In “The evidence that evidence‐based medicine omits”, Brendan Clarke and colleagues argue that when establishing causal facts in medicine, evidence of mechanisms ought to be included alongside evidence of correlations. One of the reasons they provide is that correlations can be spurious and generated by unknown confounding variables. A causal mechanism can provide a plausible explanation for the correlation, and the absence of such an explanation is an indication that the correlation is not causal. Evidence‐based medicine (EBM) proponents remain sceptical about this argument, one problem being that the formulation of a mechanism requires judgements that are external to the evaluation of data and experimental designs—for instance judgements of plausibility against, or derivability from, background knowledge. Because background knowledge is always incomplete and therefore unreliable, EBM proponents maintain that the plausibility of a hypothesis should be evaluated mainly by the quality of population data that yielded it. Here, I use the example of oestrogen replacement therapy's effect on coronary heart disease, an example that is often quoted in defence of the epistemic advantage of randomized controlled trials, to show that the evaluation of the most reliable study design necessarily implies the adoption of judgements that are external to the specific evidence of correlation. The exclusion of evidence of mechanism, therefore, is not effective in bypassing paradigm‐dependent judgements, which are external to specific evidence. Because such judgements cannot be excluded by evidence evaluation, they can only be kept under scrutiny, or adopted uncritically. I propose that the latter option can hinder the maintenance of an active critical inquiry, as well as the analysis of experts' disagreement.     

An epistemological shift: from evidence‐based medicine to epistemological responsibility

In decision making concerning the diagnosis and treatment of patients, doctors have a responsibility to do this to the best of their abilities. Yet we argue that the current paradigm for best medical practice – evidence‐based medicine (EBM) – does not always support this responsibility. EBM was developed to promote a more scientific approach to the practice of medicine. This includes the use of randomized controlled trials in the testing of new treatments and prophylactics and rule‐based reasoning in clinical decision making. But critics of EBM claim that such a scientific approach does not always work in the clinic. In this article, we build on this critique and argue that rule‐based reasoning and the use of general guidelines as promoted by EBM does not accommodate the complex reasoning of doctors in clinical decision making. Instead, we propose that a new medical epistemology is needed that accounts for complex reasoning styles in medical practice and at the same time maintains the quality usually associated with ‘scientific’. The medical epistemology we propose conforms to the epistemological responsibility of doctors, which involves a specific professional attitude and epistemological skills. Instead of deferring part of the professional responsibility to strict clinical guidelines, as EBM allows for, our alternative epistemology holds doctors accountable for epistemic considerations in clinical decision making towards the diagnosis and treatment plan of individual patients. One of the key intellectual challenges of doctors is the ability to bring together heterogeneous pieces of information to construct a coherent ‘picture’ of a specific patient. In the proposed epistemology, we consider this ‘picture’ as an epistemological tool that may then be employed in the diagnosis and treatment of a specific patient.     

Corroborating evidence‐based medicine

Proponents of evidence‐based medicine (EBM) have argued convincingly for applying this scientific method to medicine. However, the current methodological framework of the EBM movement has recently been called into question, especially in epidemiology and the philosophy of science. The debate has focused on whether the methodology of randomized controlled trials provides the best evidence available. This paper attempts to shift the focus of the debate by arguing that clinical reasoning involves a patchwork of evidential approaches and that the emphasis on evidence hierarchies of methodology fails to lend credence to the common practice of corroboration in medicine. I argue that the strength of evidence lies in the evidence itself, and not the methodology used to obtain that evidence. Ultimately, when it comes to evaluating the effectiveness of medical interventions, it is the evidence obtained from the methodology rather than the methodology that should establish the strength of the evidence.     

Reconciling evidence‐based medicine and patient‐centred care: defining evidence‐based inputs to patient‐centred decisions

Evidence‐based and patient‐centred health care movements have each enhanced the discussion of how health care might best be delivered, yet the two have evolved separately and, in some views, remain at odds with each other. No clear model has emerged to enable practitioners to capitalize on the advantages of each so actual practice often becomes, to varying degrees, an undefined mishmash of each. When faced with clinical uncertainty, it becomes easy for practitioners to rely on formulas for care developed explicitly by expert panels, or on the tacit ones developed from experience or habit. Either way, these tendencies towards ‘cookbook’ medicine undermine the view of patients as unique particulars, and diminish what might be considered patient‐centred care. The sequence in which evidence is applied in the care process, however, is critical for developing a model of care that is both evidence based and patient centred. This notion derives from a paradigm for knowledge delivery and patient care developed over decades by Dr. Lawrence Weed. Weed's vision enables us to view evidence‐based and person‐centred medicine as wholly complementary, using computer tools to more fully and reliably exploit the vast body of collective knowledge available to define patients’ uniqueness and identify the options to guide patients. The transparency of the approach to knowledge delivery facilitates meaningful practitioner–patient dialogue in determining the appropriate course of action. Such a model for knowledge delivery and care is essential for integrating evidence‐based and patient‐centred approaches.     

The need for a rationalist turn in evidence‐based medicine

When evidence‐based medicine (EBM) became established, its dominant rhetoric was empiricist, in spite of rationalist elements in its practice. Exploring some of the key statements about EBM down the years, the paper examines the tensions between empiricism and rationalism and argues for a rationalist turn in EBM to help to develop the next generation of scholarship in the field.     

Underdetermination in evidence‐based medicine

This article explores the philosophical implications of evidence‐based medicine's (EBM's) epistemology in terms of the problem of underdetermination of theory by evidence as expounded by the Duhem–Quine thesis. EBM hierarchies of evidence privilege clinical research over basic science, exacerbating the problem of underdetermination. Because of severe underdetermination, EBM is unable to meaningfully test core medical beliefs that form the basis of our understanding of disease and therapeutics. As a result, EBM adopts an epistemic attitude that is sceptical of explanations from the basic biological sciences, and is relegated to a view of disease at a population level. EBM's epistemic attitude provides a limited research heuristic by preventing the development of a theoretical framework required for understanding disease mechanism and integrating knowledge to develop new therapies. Medical epistemology should remain pluralistic and include complementary approaches of basic science and clinical research, thus avoiding the limited epistemic attitude entailed by EBM hierarchies.     

Technology‐induced bias in the theory of evidence‐based medicine

Designing trials and studies to minimize confounding and bias is central to evidence‐based medicine (EBM). The widespread use of recent technologies such as machine learning, smartphones, and the World Wide Web to collect, analyse, and disseminate information can improve the efficiency, reliability, and availability of medical research. However, it also has the potential to introduce new sources of significant, technology‐induced evidential bias. This paper assesses the extent of the impact by reviewing some of the methods by and principles according to which evidence is collected, analysed, and disseminated in EBM, supported by specific examples. It considers the effect of personal health tracking via smartphones, the current proliferation of research data and the influence of search engine “filter bubbles”, the possibility of machine learning‐driven study design, and the implications of using machine learning to seek patterns in large quantities of data, for example from observational studies and medical record databases. It concludes that new technology may introduce profound new sources of bias that current EBM frameworks do not accommodate. It also proposes new approaches that could be incorporated in to EBM theory to mitigate the most obvious risks, and suggests where further assessment of the practical implications is needed.     

Recovery of evidence‐based practice

Consumer recovery is now enshrined in the national mental health policy of many countries. If this construct, which stems from the consumer/user/survivor movement, is truly to be the official and formal goal of mental health services, then it must be the yardstick against which evidence‐based practice (EBP) is judged. From a consumer‐recovery perspective, this paper re‐examines aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence associated with EBP, those previously having been identified as deficient and in need of expansion. One of the significant differences between previous investigations and the present study is that the work, writing, perspectives, and advocacy of the consumer movement has developed to such a degree that we now have a much more extensive body of material upon which to critique EBP and inform and support the expansion of EBP. Our examination reinforces previous findings and the ongoing need for expansion. The consumer recovery‐focused direction, resources, frameworks, and approaches identified through the present paper should be used to expand the aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence. This expansion will ultimately enable services to practice in a manner consistent with the key characteristics of supporting personal recovery.     

Perceived knowledge,skills, attitude and contextual factors affecting evidence‐based practice among nurse educators,clinical coaches and nurse specialists

Evidence‐based practice (EBP) in the clinical setting is recognized as an approach that leads to improved patient outcomes. Nurse educators (NEs), clinical coaches (CCs) and nurse specialists are in key positions to promote and facilitate EBP within clinical settings and have opportunities to advance practice. Therefore, it is important to understand their perceptions of factors promoting EBP and perceived barriers in facilitating EBP in clinical settings, before developing educational programmes. This paper reports findings from a study that aimed to explore NEs' , CCs' and nurse specialists' knowledge, skills and attitudes associated with EBP. This study used a questionnaire containing quantitative and a small number of qualitative questions to capture data collected from NEs, CCs and nurse specialists working at a tertiary health‐care facility in Victoria, Australia. The questionnaire was distributed to a total of 435 people, of whom 135 responded (31%). Findings revealed that the three senior nurse groups relied heavily on personal experience, organizational policies and protocols as formal sources of knowledge. Furthermore, they had positive attitudes towards EBP. However, participants demonstrated lack of knowledge and skills in appraising and utilizing evidence into practice. They indicated a desire to seek educational opportunities to upskill themselves in the process of EBP.     

Integrating the online nursing evidence‐based information resources for evidence‐based nursing study in China

At present Chinese nurses could not get the up‐to‐date and high‐quality evidences efficiently and conveniently due to language barrier and other practical difficulties. This program built a Chinese website of integrated evidence‐based network information resources for EBN studies. Researchers hope to provide practical guidance and advice for nurses in non‐English‐speaking countries..