Journal of evaluation in clinical practice
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In modern philosophy, the concept of truth has been problematized from different angles, yet in evidence-based health care (EBHC), it continues to operate hidden and almost undisputed through the linked concept of "bias." To prevent unwarranted relativism and make better inferences in clinical practice, clinicians may benefit from a closer analysis of existing assumptions about truth, validity, and reality. In this paper, we give a brief overview of several important theories of truth, notably the ideal limit theorem (which assumes an ultimate and absolute truth towards which scientific inquiry progresses), the dominant way truth is conceptualized in the discourse and practice of EBHC. We draw on Belgian philosopher Isabelle Stengers' work to demonstrate that bias means one thing if one assumes a world of hard facts "out there," waiting to be collected. ⋯ Most importantly, it casts doubt on the ideal limit theory as it applies to the single case scenario of the clinical encounter, the cornerstone of EBHC. To the extent that the goal of EBHC is to support inferencing in the clinical encounter, then the ideal limit as the sole concept of truth appears to be conceptually insufficient. We contend that EBHC could usefully incorporate a more pluralist understanding of truth and bias and provide an example how this would work out in a clinical scenario.
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Racial discrimination has been increasingly reported to have a causal link with morbidity and mortality of Black Americans, yet this issue is rarely addressed in a public health perspective. Racism affects health at different levels: institutional racism is a structural and legalized system that results in differential access to health services; cultural racism refers to the negative racial stereotypes, often reinforced by media, that results in poorer psychological and physiological wellbeing of the minorities. Lastly, interpersonal racism refers to the persistence of racial prejudice that seriously undermines the doctor-patient relationship. ⋯ This study represents an important milestone in the application of public health on racial injustices, yet racism must be tackled with a sustained, multilevel, and interdisciplinary approach. In conclusion, this paper addresses how public health interventions can empower Black minorities and bring forward long-term policies. Racism is a structural and long-standing system that can be eliminated only with the collective effort.
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Confidence (or belief) that a therapy is effective is essential to practicing clinical medicine. GRADE, a popular framework for developing clinical recommendations, provides a means for assigning how much confidence one should have in a therapy's effect estimate. One's level of confidence (or "degree of belief") can also be modelled using Bayes theorem. In this paper, we look through both a GRADE and Bayesian lens to examine how one determines confidence in the effect estimate. ⋯ A rational thinker uses all available evidence to formulate beliefs. The GRADE criteria seem to suggest that we discard some of that information when other, more favoured information (eg, derived from clinical trials) is available. The GRADE framework should strive to ensure that the whole evidence base is considered when determining confidence in the effect estimate. The incremental value of such evidence on determining confidence in the effect estimate should be assigned in a manner that is theoretically or empirically justified, such that confidence is proportional to the evidence, both for and against it.
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The paper proposes that frameworks typical to metaphysics and art could be used in clinical treatment in somatic and psychiatric contexts to ensure improved care. The concept of the "body electric" of somatic patients which I introduced in previous work is developed further and paired with the "mind electric" of psychiatric patients. Both are defined as a patient's personally generated metaphysical possibility of being healthy-within-illness which is experientially actualized. ⋯ An argument against the idea implied by the hope for such mass treatments and corresponding overreliance on science, namely, that health comes from fixing and regularizing, is developed based on cultural history and the evidenced fact that personally assumed health, just like art and metaphysics, is transgressive of scientific data, and accommodates the untrue, the impossible or the irregular as actual and normal. Because normality is created only with the help of disorder and from within it for chronic patients, clinicians should offer them the metaphysical care they need to produce and actualize their possibility of irregular normality or their body/mind electric. Better treatments can only be provided when scientific advances will be matched with advances in the humanistic competence of clinicians.
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Evidence-based medicine is the application of research findings to inform individual clinical decisions. There is a tension-both philosophical and practical-between the average result from a population study and the circumstances and needs of an individual patient. This personal account of "evidence-based" trauma care illustrates and explores this tension. ⋯ As Sir John Grimley Evans' warned, we should avoid using evidence-based guidelines in the manner of the fabled drunkard who searched under the lamp post for his key because that was where the light was, even though he knew he had lost his key somewhere else.