Michel Accad. (2017). Moving Mountains: A Socratic Challenge to the Theory and Practice of Population Medicine. Huntsville, TX: Green Publishing House. ISBN 978-1-63432-030-6. A Dichotomization of Health?

Review of: Michel Accad. (2017). Moving Mountains: A Socratic Challenge to the Theory and Practice of Population Medicine. Huntsville, TX: Green Publishing House. ISBN 978-1-63432-030-6

The Tree of Wisdom: Maintaining epistemological health within an (emerging) evidence-free environment

Mounting concerns regarding the corruption of the clinical research enterprise by the pharmaceutical industry, as well as demonstrations of the inappropriateness of traditional research designs and consequent clinical guidelines to direct application to patient care, have led to challenges to the integrity of the evidence-based medicine (EBM) movement. However, the emerging crisis of confidence in clinical research should be seen as a threat to the viability of the entire healthcare system, not simply to EBM. Efforts of the EBM movement to represent itself as the brokers and mediators of the clinical research-healthcare interface are impediments to a full appreciation of the dilemma. Recognizing the implications of contrasting epistemological stances regarding the relationship of clinical research findings to healthcare policy and practice is essential to maximizing the value of research to the healthcare system. A synergy between empiricism-rationalism epistemologies, particularly conspicuous within the EBM movement, is identified as an important philosophical barrier to achievement of this goal. The notion of an evolutionary hierarchy of knowledge and wisdom is proposed as a vehicle to demonstrate a social constructivist alternative to a dualistic epistemology. Contrasting examples of social constructivist and empiricist-rationalist descriptions of integration of research with healthcare practice are provided for purposes of illustration

Through a Glass, Darkly: The Challenge of Integration of the Science and the Art of Medicine.

We have entered a new phase in the dialogue between proponents of evidence-based medicine and humanistic medicine. Over 30 years of parallel development of patient-centered and evidence-based care make possible concrete approaches to the integration of the fruits of these developments. Such integration is of increasing importance to the viability of today’s highly structured and regulated healthcare environment. Attempts at integrated model building on the part of proponents of both EBM and humanistic care have suffered from common deficiencies. These include the failure to distinguish between decision-making and practice models, failure to illuminate processes traversing categories of knowledge and information, failure to embrace the principles of relationship-centered care and failure adequately to address the epistemological issues inherent to the integration of the experiential and scientific domains of clinical practice. A published model-building attempt is used to illustrate what a correction of such limitations might look like. Efforts to develop person-centered care as an integrated and patient-centered vision of healthcare are encouraged

Review of: Tarnished Gold: The Sickness of Evidence-based Medicine by Steve Hickey and Hilary Roberts: EBM as an Avatar of Modern Medicine

Despite many passing references to contemporary frontiers of thought such as cybernetics and complexity theory, Tarnished Gold, a self-published book, leads the reader towards critical visions of clinical research enterprise that are more linked to the past than to the present or the future. Along the way, Evidence Based Medicine is taken as the enemy, but is consistently misrepresented. The authors are seriously under-informed regarding contemporary issues and controversies related to the design of clinical research as well as the cognitive aspects of clinical practice. They ignore the relevance of narrative and relationship-centered medicine to those issues and controversies. The actual challenges of healthcare in our time and its relationship to clinical research are largely avoided. As a result, “Tarnished Gold” fails to illuminate or inform lessons already learned from the controversies that have occurred since the appearance of EBM. More importantly, the authors fail to observe that the terms of the debate between EBM and its critics have changed in the direction of an integrative approach, based on considerations of not only the logic of scientific inference, but of contemporary understanding of clinical reasoning and of the forms of knowledge that underlie it. Some of those terms are addressed by this review

The Roadmap: a blueprint for evidence literacy within a Scientifically Informed Medical Practice and Learning Model

Background: A model of clinical practice that encompasses clinical relationships and choices as well as the use of clinical research has yet to be elaborated. We sought a model for Scientifically Informed Medical Practice and Learning (SIMPLE) through integrating concepts borrowed from narrative medicine with the results of a competency-based assessment project. Methods: The SIMPLE model started by subordinating the cognitive skills within an information literacy model (‘ask’, ‘acquire’, ‘appraise’ and ‘apply’) to the content of clinical actions (‘therapy’, ‘diagnosis’, ‘prognosis’ and ‘harm’). This enabled a description of problem delineation. The content of these components was developed through an iterative, reflexive approach, elaborating distinctions across all action domains. This led to the “Road Map” component of the model. Clinical action domains were defined within a relational construct. Results: We defined 3 sub-categories of Problem (utility, performance and likelihood) leading to shared Actions, Choices and Targets (PACT) within the SIMPLE model as a bridge between relational and information literacy fields. The enabling skill ‘ask’ and the “Patients, Interventions, Comparisons, Outcomes” (PICO) format, was applied uniformly across these categories. ‘Acquire’ was elaborated using a 3-S format (Summaries, Syntheses, Single studies) that links study designs to electronic sources (published synopses, filtered databases and large bibliographical databases). ‘Appraise’ involved evaluation of design-specific susceptibility to error and of importance of the results classified as measures of frequency, effect, impact and precision. Finally, ‘apply’ included assessment of directness of evidence, contextual issues and overall benefits versus risks. Translation of knowledge into action involved constructed priorities and preferences within the relational field. Conclusion: The Road Map enables linkage of a broad range of patient and practitioner concerns related to clinical action to a comparably broad spectrum of contemporary clinical research. It may usefully guide curricular and instructional approaches. Empirical validation in improving learning outcomes is required

“Practitioner Wellness, Person Centered Healthcare, Reflective Practice and the Mission of Mindfulness Training. ” Commentary on Garneau, K., Hutchinson, T., Zhan, Q. & Dobkin, P.L. (2013). Cultivating Person-Centered Medicine in Future Physicians. European Journal of Person Centered Medicine 1 (2) 468-477

A primary purpose of healthcare is the enhancement of health, wellbeing and in understanding and responding to the illness experience in individual patients

Survey of preferred guideline attributes: what helps to make guidelines more useful for emergency health practitioners?

Background: Enhancing CPG acceptance and implementation can play a major role in the development and establishment of emergency medicine as a specialty in many parts of the world. A Guideline International Network special interest group established to support collaboration to improve uptake of clinical practice guidelines (CPGs) across the emergency care sector conducted an international survey to identify attributes of guideline likely to enhance their use. Methods: A Web-based survey was undertaken to determine how CPGs were accessed, the preferred formats and attributes of guidelines, and familiarity with GRADE. The criteria used to identify preferred attributes of guidelines were adapted from the AGREE II Tool. Results: Two hundred six responses were received from 31 countries, 74/206 (36%) from the US, 28/206 (16%) from Canada, 17/206 (8%) from Australia and 15/206 (7%) from the UK. The majority of responses were from physicians (176/206, 85%) with 15/206 (7%) of responses from nurses and 9/206 (4%) from pre-hospital emergency services personnel. The preferred format for guidelines was clinical protocols that incorporated recommendations into workflow, and the most preferred attribute of guidelines was the clear identification of key recommendations. The results also identified that within the group that responded to the question related to GRADE, 66% were unfamiliar with this system for summarizing evidence in relationship to recommendations. Conclusions: The findings provide the basis for further research to explore the most appropriate formats for guidelines or guidelines resources tailored to the needs of the emergency care providers

Tips for Teachers of Evidence-based Medicine: Making Sense of Decision Analysis Using a Decision Tree

Decision analysis is a tool that clinicians can use to choose an option that maximizes the overall net benefit to a patient. It is an explicit, quantitative, and systematic approach to decision making under conditions of uncertainty. In this article, we present two teaching tips aimed at helping clinical learners understand the use and relevance of decision analysis. The first tip demonstrates the structure of a decision tree. With this tree, a clinician may identify the optimal choice among complicated options by calculating probabilities of events and incorporating patient valuations of possible outcomes. The second tip demonstrates how to address uncertainty regarding the estimates used in a decision tree. We field tested the tips twice with interns and senior residents. Teacher preparatory time was approximately 90 minutes. The field test utilized a board and a calculator. Two handouts were prepared. Learners identified the importance of incorporating values into the decision-making process as well as the role of uncertainty. The educational objectives appeared to be reached. These teaching tips introduce clinical learners to decision analysis in a fashion aimed to illustrate principles of clinical reasoning and how patient values can be actively incorporated into complex decision making