The effects of varying forms and degrees of government intervention upon the effective competitiveness of UK small businesses

This doctoral thesis responds to the need for greater understanding of small businesses and their inherent unique problem-types. Integral to the investigation is the theme that for governments to effectively influence small business, a sound understanding of the factors they are seeking to influence is essential. Moreover, the study, in its recognition of the many shortcomings in management research and, in particular that the research methods and approaches adopted often fail to give adequate understanding of issues under study, attempts to develop an innovative and creative research approach. The aim thus being to produce, not only advances in small business management knowledge from the standpoints of government policy makers and `lq recipient small business, but also insights into future potential research method for the continued development of that knowledge. The origins of the methodology lay in the non-acceptance of traditional philosophical positions in epistemology and ontology, with a philosophical standpoint of internal realism underpinning the research. Internal realism presents the basis for the potential co-existence of qualitative and quantitative research strategy and underlines the crucial contributory role of research method in provision of ultimate factual status of the assertions of research findings. The concept of epistemological bootstrapping is thus used to develop a `lq partial research framework to foothold case study research, thereby avoiding limitations of objectivism and brute inductivism. The major insights and issues highlighted by the `lq bootstrap, guide the researcher around the participant case studies. A novel attempt at contextualist (linked multi-level and processual) analysis was attempted in the major in-depth case study, with two further cases playing a support role and contributing to a balanced emphasis of empirical research within the context of time constraints inherent within part-time research

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

Person centered healthcare and clinical research: the necessity of an evolutionary hierarchy of knowing and doing

Effective person-centred care requires recognition of the personhood not only of patients but of practitioners. This chapter explores the consequences of this recognition for major debates in medical epistemology, regarding clinical reasoning and the relationship between research and practice. For too long these debates have been dominated by false dichotomies - subjectivity versus objectivity, judgement versus evidence, reason versus emotion. Based on flawed understandings of such core concepts as “objectivity” and “engagement”, this distorted dissection of the subject-object relationship has served to depersonalise practice. The costs of this depersonalisation include over-regulation and micromanagement of healthcare processes by administrators and payers at the same time that information from clinical research remains under-utilized and the personhood of patients risks being ignored. Science is a human practice, founded in a broader conception of human reasoning, ontologically dependent on human beings living and engaging with the world in social, emotional and ethical contexts. After looking at different conceptions of epistemic hierarchies and their uses in the analysis and evaluation of reasoning in a range of practice contexts, we propose a “nested hierarchy” that effectively turns upside-down the flawed evidence hierarchies that have helped to depersonalise care. T.S. Eliot’s “wisdom, knowledge, information” scheme (to which we add “data” below “information”) provides a model for a person-centred epistemic hierarchy. This crucial, person-centred inversion represents levels of awareness that characterise more or less developed thinking and judgement on the part of the particular practitioner

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

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.

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

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

Form follows function: pragmatic controlled trials (PCTs) have to answer different questions and require different designs than randomized controlled trials (RCTs).

Aim Rising concern for demonstrated real world comparative effectiveness has heightened interest in “pragmatic trials” design. Pragmatic trials investigate whether the efficacy, presumed or found in explanatory trials under ideal conditions, can also be detected under real world conditions, i.e. effectiveness. It is also recognized that ‘real world’ effects which are usually addressed in public health research gain growing interest in confirming the ‘road capability’ of results obtained under ideal study conditions. This paper demonstrates that studies under ideal or real world conditions use different methods, generate different information and cannot replace each other. Subjects and methods The PCT design meets four requirements of public health and of effectiveness research. It includes all individuals who presented with the selected condition. It classifies the included individuals according to baseline risks. It enables plausibility controls. Finally, it compares the outcomes resulting from specified and notspecified interventions or treatments. Proposal We propose a pragmatic controlled trial (PCT) design in which patient preference and other co-factors crucial in determining the actual effectiveness of interventional options will not be neutralized by concealed randomization and blinding. This design is applicable to record the selected interventions and generated outcomes in day-to-day health care and is capable of incorporating preference and other participative factors into assessment of effectiveness. Conclusions The PCT design is useful for public health research, e.g. the effectiveness of interventions to change smoking habits or to prevent death frombreast cancer, as well as for comparative effectiveness research where it will supplement the traditional randomized controlled trial (RCT)

“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