Journal of evaluation in clinical practice
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The foundationalist and anti-foundationalist conceptions of medical knowledge have been at loggerheads for decades. Evidence-based medicine (EBM), the most prominent form of foundationalism, has attained wide appeal and acceptance among authorities. It proposes that evidence is the "base" upon which all clinical decisions should be grounded. ⋯ In this paper, I provide a survey of the foundationalist and anti-foundationalist debate in medicine and defend anti-foundationalism on the basis that foundationalist approaches are anachronistic, and in the case of evidence-based medicine ultimately confuses inputs (evidence) for consideration in making a judgement with outputs (conclusions). I further propose that virtue ethics is inseparable from anti-foundationalism and conclude that the current infatuation with EBM implies something rather troubling; that physicians cannot be trusted to utilize their extensive training and skills to make reasonable decisions in the best interests of their patients. If this is in fact true, it suggests a crisis in virtue amongst medical professionals.
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The recent emphasis on value-based health care (VBHC) is thought to provide new opportunities for shared decision-making (SDM) in the Netherlands, especially when using patient-reported outcome measures (PROMs) in routine medical encounters. It is still largely unclear about how PROMs could be linked to SDM and what we expect from clinicians in this respect. ⋯ Successful implementation of SDM within VBHC initiatives may not be self-evident, even though individual, N = 1 PROMs scores are being used in the medical encounter. Education and staff resources on meso and macro levels may facilitate the more time-consuming SDM aspects. It seems fruitful to especially target team talk and choice talk in redesigning clinical pathways.
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The way in which care providers describe incapacitated elderly people is not without implications. The different ways in which they describe their patients-client, patient, or a sick human being-have consequences for their relationships with these patients and the decision-making processes. The aim of this study is to use insights from complexity thinking to understand the dynamic relations between various patient descriptions in decision-making. ⋯ Shared-decision-making favours the involvement of patients and their families in decision-making. However, due to a domination of the logic of the market and the logic of medicine, decision-making is problematic. As professional mediators, health care providers learn, however, to balance client demands, medical perspectives, and embodied dialogic care in decision-making for voiceless patients.