Professional judgement in clinical practice (part 3): A better alternative to strong evidence‐based medicine

Abstract

Parts 1 and 2 in this series of three articles have shown that and how strong evidence-based medicine has neither a coherent theoretical foundation nor creditable application to clinical practice. Because of its core commitment to the discredited positivist tradition it holds both a false concept of scientific knowledge and misunderstandings concerning clinical decision-making. Strong EBM continues attempts to use flawed adjustments to recover from the unsalvageable base view. Paper three argues that a promising solution is at hand if we can manage several modes of inclusion. A modified original, moderate version of EBM continues though usually overshadowed. As definitively laid out by Sackett in the 1990s, clinical decision making is intended to be person-centered, recognizing and integrating multiple modes of evidence and knowledge that have been marginalized: professional experience, illness narratives, and individual patients' values and preferences. Complementary resources are at hand: interpretative understanding and practice, such as philosophical anthropology, hermeneutical phenomenology, complexity theory, and phronetic practices respond to the major problems and open new possibilities. Phronesis is especially important in regard to public decision making. Within part 3 an additional tone necessarily occurs. While most of papers 1, 2, and 3 are written in the classical mode of contrasting the theoretical-logical and empirical evidence offered by contending positions bearing on the decision making and judgement in clinical practice, a shift occurs when considerations move beyond what is possible for clinical practitioners to accomplish. A different, discontinuous level of power operates in the trans-personal realm of instrumental policy, insurance, and hospital management practices. In this social-economic-political-ethical realm what happens in clinical practice today increasingly becomes a matter of what is "done unto" clinical practitioners, of what hampers their professional action and thus care of individual patients and clients.

Bio‐ethical issues in oncology during the first wave of the COVID‐19 epidemic: A qualitative study in a French hospital

“… 56 , 57 , 58 , 59 , 60 , 61 The pandemic showed the shortcomings of the dominant conception of EBM, which limits the possibilities of clinical decision‐making under conditions of uncertainty and lack of consolidated knowledge. 62 The many benefits of EBM to patients are undeniable. 61 Nevertheless, we can see a limitation of this approach here.…”

“…Based on both these clinical experiences and the scientific literature, we clearly identified a first bio‐ethical issue: the inadequacy of state‐of‐the‐art practices during the first wave 56–61 . The pandemic showed the shortcomings of the dominant conception of EBM, which limits the possibilities of clinical decision‐making under conditions of uncertainty and lack of consolidated knowledge 62 . The many benefits of EBM to patients are undeniable 61 .…”

Conceptualizations of health, ability to act upon those definitions and desire for supports among families from historically marginalized communities

“…FCC is the foundation for clinician–parent partnership. Our study is one of few providing insight into opportunities to improve FCC for families from historically marginalized communities, highlighting the need to understand each family's context and provide supports that meets people's needs and accounts for their challenges (Browne et al, 2012; Mugerauer, 2021; Sheldrick et al, 2021). One important step is eliciting parents' multidimensional conceptualizations of health; we found that parents' definitions broadly reflect flourishing, a popular concept focusing on social and cultural factors that are central to conceptualizations of well‐being (de Ruyter et al, 2020).…”

Humans, machines and decisions: Clinical reasoning in the age of artificial intelligence, evidence‐based medicine and Covid‐19

“…The section includes papers on EBM but extends beyond EBM to broader philosophical discussions concerning clinical knowledge, causal reasoning, research and consent-discussing issues of person-centred care and the purpose of medicine, and challenges to clinical judgement presented by the need for virtual care, a need generated by the global pandemic. [17][18][19][20][21][22][23][24][25][26][27] The first three papers in the section [17][18][19] take up the issues that were the topic of the concluding papers in the preceding 'Humanities' section, 15,16 though in this case the author outlines the history of the EBM debate from the perspective of medical philosophy and the history of ideas. The papers provide an extremely helpful account and critical analysis of the debate over the last 30 years, concluding with arguments concerning the possibilities for future development and the relationship between EBM and complexity theory, providerpatient decision making and person-centred care.…”