Abstract:Over the last 20 years, the evidence-based medicine (EBM) movement has sought to develop standardised approaches to patient treatment by drawing on research results from randomised controlled trials (RCTs). The Cochrane Collaboration and its eponym, Archie Cochrane, have become symbols of this development, and Cochrane's book from 1972 is often referred to as the first sketch of what was to become EBM. In this article, we claim that this construction of EBM's historical roots is based on a selective reading of… Show more
“…This was not intended. For Archie Cochrane, who the early EBM proponents often cited in support of their view, health care had 2 equality important dimensions: I see the NHS, rather crudely, as supplying on the one hand therapy, and on the other board and lodging and tender, loving, care …”
Section: Discussionmentioning
confidence: 99%
“…I see the NHS, rather crudely, as supplying on the one hand therapy, and on the other board and lodging and tender, loving, care …”
Section: Discussionmentioning
confidence: 99%
“…For Archie Cochrane, who the early EBM proponents often cited in support of their view, health care had 2 equality important dimensions: I see the NHS, rather crudely, as supplying on the one hand therapy, and on the other board and lodging and tender, loving, care. 42 Purification and hybridization have their place, but not predominantly. Health care is about making good inferences (which is the role of EBHC), about equity, and about relationship-based, loving care.…”
Section: We Contend That Any New Interpretation Of Ebhc Should Notmentioning
Evidence‐based health care (EBHC), previously evidence‐based medicine (EBM), is considered by many to have modernized health care and brought it from an authority‐based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC.In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latour's work, we argue that the early EBM movement had a strong modernist agenda with an aim to “purify” clinical reality into a dichotomy of objective “evidence” from nature and subjective “preferences” from human society and culture.However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition—albeit implicit and undertheorized—that evidence in clinical decision making is relentlessly situated and contextual. The unique, individual patient, not abstracted truths from distant research studies, must be the starting point for clinical practice. It follows that the EBHC community needs to reconsider the assumption that science should be abstracted from culture and acknowledge that knowledge from human culture and nature both need translation and interpretation. The implications for clinical reasoning are far reaching. We offer some preliminary principles for conceptualizing EBHC as a “situated practice” rather than as a sequence of research‐driven abstract decisions.
“…This was not intended. For Archie Cochrane, who the early EBM proponents often cited in support of their view, health care had 2 equality important dimensions: I see the NHS, rather crudely, as supplying on the one hand therapy, and on the other board and lodging and tender, loving, care …”
Section: Discussionmentioning
confidence: 99%
“…I see the NHS, rather crudely, as supplying on the one hand therapy, and on the other board and lodging and tender, loving, care …”
Section: Discussionmentioning
confidence: 99%
“…For Archie Cochrane, who the early EBM proponents often cited in support of their view, health care had 2 equality important dimensions: I see the NHS, rather crudely, as supplying on the one hand therapy, and on the other board and lodging and tender, loving, care. 42 Purification and hybridization have their place, but not predominantly. Health care is about making good inferences (which is the role of EBHC), about equity, and about relationship-based, loving care.…”
Section: We Contend That Any New Interpretation Of Ebhc Should Notmentioning
Evidence‐based health care (EBHC), previously evidence‐based medicine (EBM), is considered by many to have modernized health care and brought it from an authority‐based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC.In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latour's work, we argue that the early EBM movement had a strong modernist agenda with an aim to “purify” clinical reality into a dichotomy of objective “evidence” from nature and subjective “preferences” from human society and culture.However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition—albeit implicit and undertheorized—that evidence in clinical decision making is relentlessly situated and contextual. The unique, individual patient, not abstracted truths from distant research studies, must be the starting point for clinical practice. It follows that the EBHC community needs to reconsider the assumption that science should be abstracted from culture and acknowledge that knowledge from human culture and nature both need translation and interpretation. The implications for clinical reasoning are far reaching. We offer some preliminary principles for conceptualizing EBHC as a “situated practice” rather than as a sequence of research‐driven abstract decisions.
“…To deal with the first point, the concept of health care as caring, loving and nurturing has been argued to largely have been lost in the process of commissioning (Wieringa et al, 2017). The NHS on one hand provides therapy but on the other, board and lodging and tender loving care (Askheim, Sandset, & Engebretsen, 2017). In the UK, hospitals in particular play an important symbolic role; they are more than just buildings where healthcare is delivered.…”
The Brighton Citizen's Health Services Survey (BCHSS) was developed to explore and potentially challenge how knowledge is used and by whom in the production of local health commissioning institutions and relations. Through the creation of an 'animating set of questions', it sought to open up spaces through which to make visible some of the ways of knowing and valuing the NHS and health services that had been minimised through the commensuration practices of post-2012 public engagement. In this way there was a clear agenda to facilitate a form of knowledge democratisation which opened up and validated different 'health publics', in order to explore and broaden participative engagement opportunities. The paper provides an account of the project. It considers the theoretical and methodological underpinnings of this example of 'evidence-based activism', reflects on the impact of the project on local commissioning and considers the range of controversies that arose as a result of the work. It explores the way that research straddling the boundary between academic inquiry and political activism speaks to the many issues that are prevalent in the changing HE sector as well as NHS privatisation, health commissioning and public sector cuts.
“…They argued that clinical expertise and patient preferences should be “integrated” with best research evidence [ 3 ]. Contrary to how some critics depicted EBM , “best” evidence was not considered to be synonymous with a simple and restrictive hierarchy of evidence, as some clinical questions are best addressed using study designs other than RCTs or because there are some questions for RCT evidence that is impossible to obtain or unavailable [ 4 ]. Despite this early call for a pluralist approach to evidence in guideline development, standards and checklists for assessing the quality of guidelines (notably the Grading of Recommendations Assessment, Development and Evaluation recommendations [ 5 ]) can sometimes depict an overly hierarchical approach, inadvertently privileging RCTs even when these are not appropriate and making it difficult to give appropriate weight to knowledge from non-RCT study designs.…”
BackgroundAs a response to the criticisms evidence-based practice currently faces, groups of health care researchers and guideline makers have started to call for the appraisal and inclusion of different kinds of knowledge in guideline production (other than randomized controlled trials [RCTs]) to better link with the informal knowledge used in clinical practice. In an ethnographic study, Gabbay and Le May showed that clinicians in everyday practice situations do not explicitly or consciously use guidelines. Instead, they use mindlines: collectively shared, mostly tacit knowledge that is shaped by many sources, including accumulated personal experiences, education (formal and informal), guidance, and the narratives about patients that are shared among colleagues. In this study on informal knowledge, we consider virtual networks of clinicians as representative of the mindlines in the wider medical community, as holders of knowledge, as well as catalysts of knowing.ObjectiveThe aim of this study was to explore how informal knowledge and its creation in communities of clinicians can be characterized as opposed to the more structured knowledge produced in guideline development.MethodsThis study included a qualitative study of postings on three large virtual networks for physicians in the United Kingdom, the Netherlands, and Norway, taking the topic of statins as a case study and covering more than 1400 posts. Data were analyzed thematically with reference to theories of collaborative knowledge construction and communities of practice.ResultsThe dataset showed very few postings referring to, or seeking to adhere to, explicit guidance and recommendations. Participants presented many instances of individual case narratives that highlighted quantitative test results and clinical examination findings. There was an emphasis on outliers and the material, regulatory, and practical constraints on knowledge use by clinicians. Participants conveyed not-so-explicit knowledge as tacit and practical knowledge and used a prevailing style of pragmatic reasoning focusing on what was likely to work in a particular case. Throughout the discussions, a collective conceptualization of statins was generated and reinforced in many contexts through stories, jokes, and imagery.ConclusionsInformal knowledge and knowing in clinical communities entail an inherently collective dynamic practice that includes explicit and nonexplicit components. It can be characterized as knowledge-in-context in practice, with a strong focus on casuistry. Validity of knowledge appears not to be based on criteria of consensus, coherence, or correspondence but on a more polyphonic understanding of truth. We contend that our findings give enough ground for further research on how exploring mindlines of clinicians online could help improve guideline development processes.
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