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

Abstract

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.

Interdisciplinary education: a case study

“…A cross-sectional approach is taken by data gathering through interviews and a number of additional documents have been used to triangulate these same parameters. The interviews were semi-open (audio-recorded and then transcribed) and were realised in accordance with the framework on interdisciplinary learning developed by a consortium of the three Technical Universities (Twente, Eindhoven and Delft) in the Netherlands (Van den Beemt et al forthcoming; Baalen and Boon 2015). 2 The transcriptions and interpretations for the 3TU Framework have been validated -each interview interpretation has been reviewed by a peer of the other institution.…”

A social‐technological epistemology of clinical decision‐making as mediated by imaging

“…Decision‐making in the PH clinic involves combining evidence from heterogeneous sources, such as the patient's history, clinical examination, lab tests, images and measurements, awareness of personal and social circumstances, observations of the patient by clinicians on ward rounds and by ward staff, or interactions with family. One of the key epistemological challenges of clinicians is to develop an account of every individual patient based on the available evidence, a process that involves the interpretation and adjustment of pieces of evidence so that they form a cohesive and consistent “picture” of that patient . These pieces of evidence are generated and interpreted by different people; for example, radiographers generate images by operating the imaging apparatus when the patient is scanned, and by doing initial data processing—which is in a sense, already a first form of interpretation; radiologists interpret the images, but so too do clinicians, with different levels of expertise.…”

“…One of the key epistemological challenges of clinicians is to develop an account of every individual patient based on the available evidence, a process that involves the interpretation and adjustment of pieces of evidence so that they form a cohesive and consistent "picture" 2 of that patient. 35 These pieces of evidence are generated and interpreted by different people; for example, radiographers generate images by operating the imaging apparatus when the patient is scanned, and by doing initial data processing-which is in a sense, already a first form of interpretation; radiologists interpret the images, but so too do clinicians, with different levels of expertise. Nurses and clinicians generate evidence through the patient history and clinical relationship, and their interpretation provides the clinical questions that radiologists use to direct their interpretation of the images.…”

Diseases, patients and the epistemology of practice: mapping the borders of health, medicine and care

“…Sophie van Baalen and Mieke Boon argue that EBM does not provide sufficient resources for physicians to engage in proper clinical reasoning [23]. In particular, the evidence and the decision support methods provided by EBM are unable to support the kind of epistemic responsibility that doctors must take for their diagnostic and treatment decisions.…”