Journal of evaluation in clinical practice
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This paper aims to show how the focus on eradicating bias from Machine Learning decision-support systems in medical diagnosis diverts attention from the hermeneutic nature of medical decision-making and the productive role of bias. We want to show how an introduction of Machine Learning systems alters the diagnostic process. Reviewing the negative conception of bias and incorporating the mediating role of Machine Learning systems in the medical diagnosis are essential for an encompassing, critical and informed medical decision-making. ⋯ We show that Machine Learning systems join doctors and patients in co-designing a triad of medical diagnosis. We highlight that it is imperative to examine the hermeneutic role of the Machine Learning systems. Additionally, we suggest including not only the patient, but also colleagues to ensure an encompassing diagnostic process, to respect its inherently hermeneutic nature and to work productively with the existing human and machine biases.
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Evidence-based medicine (EBM), the dominant approach to assessing the effectiveness of clinical and public health interventions, focuses on the results of association studies. EBM+ is a development of EBM that systematically considers mechanistic studies alongside association studies. ⋯ (a) Assessment of combination therapy for MERS highlights the need for systematic assessment of mechanistic evidence. (b) That hypertension is a risk factor for severe disease in the case of SARS-CoV-2 suggests that altering hypertension treatment might alleviate disease, but the mechanisms are complex, and it is essential to consider and evaluate multiple mechanistic hypotheses. (c) Confidence that public health interventions will be effective requires a detailed assessment of social and psychological components of the mechanisms of their action, in addition to mechanisms of disease. (d) In particular, if vaccination programmes are to be effective, they must be carefully tailored to the social context; again, mechanistic evidence is crucial. We conclude that coronavirus research is best situated within the EBM+ evaluation framework.
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Proponents of clinical case formulations argue that the causes and mechanisms contributing to and maintaining a patient's problems should be analysed and integrated into a case conceptualization, on which treatment planning ought to be based. Empirical evidence shows that an individualized treatment based on a case formulation is at least sometimes better than a standardized evidence-based treatment. ⋯ We show how PACT works in practice by discussing treatment planning for a clinical case involving symptoms of social anxiety, depression and post-traumatic stress disorder.
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This paper explores the possibility of AI-based addendum therapy for borderline personality disorder, its potential advantages and limitations. Identity disturbance in this condition is strongly connected to self-narratives, which manifest excessive incoherence, causal gaps, dysfunctional beliefs, and diminished self-attributions of agency. ⋯ The suggestion of this paper is that human-to-human therapy could be complemented by AI assistance holding out the promise of making patients' self-narratives more coherent through improving the accuracy of their self-assessments, reflection on their emotions, and understanding their relationships with others. Theoretical and pragmatic arguments are presented in favour of this idea, and certain technical solutions are suggested to implement it.
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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. ⋯ 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.