Search Results

This chapter examines the impact of “evidence-based medicine” (EBM) on global public health. An epistemic transformation in the field of global health is underway, and it argues that the impact of EBM has been twofold: (1) the creation of an experimental metric as a means of providing health care; and (2) a shift in the priorities of caregiving practices in public health such that “people [no longer] come first.” The production of experimental research populations in and through EBM helps constitute larger fiscal transformations in how we do global health. Notably, EBM has created a platform for the buying and selling of truth and reliability, abstracting clinical caregiving from the social relationships on which they depend.

This chapter includes five sections which cover the following topics: (1) the relevant background issues, including definitions, providing an overview of evidence-based medicine, and other concepts underlying evidence-based public health (EBPH); (2) several key characteristics of an evidence-based process; (3) analytic tools to enhance the uptake of EBPH; (4) a brief sketch of a framework for EBPH in public health practice; and (5) a summary of barriers and opportunities for widespread implementation of evidence-based approaches. A big goal of this introductory chapter is to move the process of decision making toward a proactive approach that incorporates effective use of scientific evidence and data.

Values-based medicine (VBM) is the theory and practice of effective health-care decision making for situations in which legitimately different (and hence potentially conflicting) value perspectives are in play. As a theory, VBM is the values counterpart of Evidence-Based Medicine (EBM). VBM and EBM are both responses to the growing complexity of decision making in health care: EBM is a response to the growing complexity of the relevant facts; VBM is a response to the growing complexity of the relevant values. As a practice, VBM is a skills-based counterpart of the currently dominant quasi-legal form of clinical bioethics. VBM emphasizes the importance of good process in the form particularly of improved clinical practice skills. This chapter discusses the ten principles of VBM.

Studies consistently show that health care practitioners are poor at processing statistical information on risk. Indeed, almost everybody in health care, apart from a few people with advanced training, is poor at processing statistical information. The inability to process statistical information among health care practitioners is one cause of patients failing to receive optimal care. But there are many others, including a flawed and biased information base, unawareness of evidence, unwillingness to accept the evidence, lack of applicability of the evidence, inability to implement treatments, failures to act, unwillingness of patients to accept evidence, and failure to adhere to treatments. Commissioners of health care and those who set policy may be in a much stronger position than practitioners to follow evidence, as they have access to expert advice and are not under the same time pressures as practitioners. The reductionist ideas of evidence-based medicine, however, are not simply applied in commissioning and the making of policy. Improvement is most likely to come with a systems approach, making it easy for practitioners to use interventions based on evidence and more difficult to use those not based on evidence.

Why do we need to consider evidence for population health and how can it draw on the success of evidence-based medicine? This chapter describes the Population Health Evidence Cycle: Ask, collect; understand; use.

This chapter begins with an account of the development of the elements of evidence-based medicine: the randomized controlled trial, evidence hierarchies, meta-analysis, and systematic review. It discusses the relationship of evidence-based medicine to the medical decision-making movement. It focuses on one criticism of evidence-based medicine: the claim that evidence-based medicine ignores the basic sciences that guide both research and clinical practice. This is because evidence hierarchies put “pathophysiological reasoning” at the bottom, or leave it off the hierarchy altogether. Several philosophers of science suggest that this be remedied by adding some high-quality “mechanistic evidence” to the middle or upper levels of the evidence hierarchy. The chapter argues instead that we regard evidence-based medicine as only one of the methods needed in medicine.

This chapter recounts the emergence of orthodox medicine. Medical care and medical education emerged as a scientific enterprise in the last quarter of the nineteenth century, with the help of the advances in germ theory, anti-septic techniques, hygiene, anesthesia, and surgery. By the turn of the twentieth century, orthodox medicine succeeded in eliminating a number of unconventional therapies, challenging philosophy-based practices through “evidence-based medicine” (EBM). Biomedicine treated disease as a biochemical phenomenon that could be classified into discrete categories of causation using standardized, objectified, and technologically validated biochemical treatments and mechanisms. This led to the evolution of clinical trials, such as the blind or masked (placebo) assessment; the double-blind, placebo-controlled randomized clinical trial (RCT); and the so-called Cochrane Collaboration, which incorporated meta-analysis to support RCT's predictions.

Chapter 1 introduces consensus conferences, evidence-based medicine, translational medicine and narrative medicine. It shows that each was introduced with claims about how transformative for medicine it would prove to be. It motivates the book by raising initial questions about each method that are not answered by the current literature. The traditional bifurcation between the art and the science of medicine is an obstacle to a fuller understanding of the methods. The tools of recent philosophy of science, integrated history and philosophy of science, science and technology studies and, most specifically, historical epistemology, guides the investigation. An outline of the contents, chapters, and conclusions is given.

This chapter sets the groundwork for answering the book’s central question, How does the notion of evidence determine the boundaries of biomedicine, from expert to public contexts? It explains the rhetorical significance of terms such as “evidence” and “boundaries” within biomedicine and medical and professional discourse. Contemporary debates about complementary and alternative medicine (CAM) are shaped by the emergence of Evidence-Based Medicine as a qualitatively new model of medical practice, in which quantitative research data derived from clinical trials abstract medical decision-making from the physicians and researchers who engage in it. This chapter shows how recourse to “the evidence” in debates about CAM interventions can operate as a strategy of exclusion, wherein arguments about whether or not a given health practice is safe and effective are embedded within the medical-disciplinary matrices out of which they emerge.

The focus of the book is the issue of how to diffuse and implement innovations. This has become a burgeoning area of research in many organizations including health care. This chapter introduces the structure of the book and raises key issues.

This chapter focuses on scientific method as the key rhetorical topos, or topic, within evidence-based medicine that furnishes lines of argument that researchers adopt to align complementary and alternative medicine (CAM) with scientific boundaries. At the core of debates about CAM is an epistemological debate about how research on CAM ought to be conducted, interpreted, and incorporated into practice because biomedicine’s “gold standard” methodology, the randomized controlled trial (RCT), does not easily accommodate interventions such as acupuncture. The chapter examines how CAM practices fit awkwardly within the RCT format and, turning to studies of experimental articles in rhetoric of science, rhetoric of medicine, and genre theory, investigates how the experimental genre is mobilized in the specific case of biomedical CAM research. It then isolates the concept of efficacy—whether or not a health intervention “works”—as a central organizing principle of biomedical research on CAM. The chapter shows that efficacy can be invoked strategically to draw epistemic and professional boundaries. As this chapter argues, the problem of method in biomedical CAM research is largely a problem of persuasion: the ways that researchers design their studies and report their findings determine which health interventions belong in biomedicine and which do not.

Central to the question of methodology in research on complementary and alternative medicine (CAM) is the practitioner-patient relationship, the most unambiguously rhetorical element of clinical medicine. Increased interaction between practitioners and patients in any medical model may have unintended—and unquantifiable—therapeutic effects. Chapter Four examines how research on CAM configures practitioner-patient interaction, particularly in relation to prevalent models of medical practice, including patient-centered care and evidence-based medicine. It argues that studies of CAM posit practitioner-patient interaction as a potential contaminant in trials of acupuncture and chiropractic, wherein attempts to control for placebo effects are, in many cases, attempts to control for interaction effects. Probing these interaction effects can further contribute to new understandings of how practitioner-patient encounters can influence health outcomes. Finally, the chapter examines patient autonomy, closely linked to interaction and central to discourses about CAM both in the texts under study and I medical discourse more generally. The actual extent of autonomy afforded to patients in medical settings, alternative or not, is often illusory, framed within generic and rhetorical processes that necessarily tilt the course of decision-making in particular, and predictably biomedical, directions.

This chapter examines the rise of postmodernism in the second half of the twentieth century and the epistemological challenges it forced upon the core values of scientific positivism. Postmodernism viewed objectivity as an illusion, a set of images or metanarratives that fragmented both reason and meaning. Applied to medicine, it questioned the “truth” of the physician's reductionist account of illness, including those conclusions drawn from evidence-based medicine (EBM). It also revolted against patient objectification, inferring that the “truth” of an illness is no longer in the physician's objectivist and biomedical account, but in the patient's narrative. This resulted in the rise of complementary and alternative medicine (CAM), a more intuitive and individualized approach to medicine. This new representation of illness involves social, psychological, and cultural components; innovative new discourses on pain, suffering, and empathy; and perceived limitations of the dominant biochemical model.

To improve health care journalism, criteria and assessment strategies are needed. This has proven difficult due to the various definitions of quality used by science and journalism. Recommendations are made to integrate these varying perspectives into a usable set of quality criteria. Ranking the quality of health news must be conducted on the basis of consistent criteria. Several strategies are presented to improve evaluation. A two-step model is proposed to increase the quality of investigation and presentation in science journalism. This model is accessible to highly specialized as well as general journalists. An overview is provided of the basic rules in journalistic presentation, and the effects of medical reporting among recipients are discussed. Health reporting in the media and the quality debate concerning direct consumer/patient information (via Internet) is highlighted. Finally, the future role of health care journalism, journalists, and “personal evidence scouts” is discussed in the context of a rapidly changing and fragmented media world.

Most stakeholders in the health care system—doctors, patients, and policy makers—have not been taught to apply evidence-based information to the many decisions that must be made daily. Little awareness of this problem exists, yet a better use of evidence could improve outcomes for patients, increase patient satisfaction, and lower costs. This chapter considers how the use of information that emerges from evidence-based medicine could be improved. Health literacy is the first step. After a discussion of the barriers that exist to health literacy, possible remedies are presented. Raising health literacy by targeting individual stakeholder groups is debated as is the option of focusing on change in the overall health system. What is required to achieve a change both at the individual and system levels? Solutions are unlikely to generate systemic changes in center-based treatment variations. However, a change at one level may set off change in another. Finally, increasing awareness beyond the immediate professional community is necessary if systemic changes are to be made. The promotion of health literacy requires careful consideration to reach the various stakeholders throughout the health care system.

Both evidence-based medicine (EBM) and biological psychiatry aim to improve clinical practice by basing it more firmly on the results of scientific research. In this chapter, however, I show that the two approaches have very different views on what kinds of research will improve practice. This is because EBM is a form of medical empiricism – it focuses solely on whether treatments work, while biological psychiatry is a form of medical rationalism – it seeks to understand the causes that give rise to observed clinical outcomes. I argue that EBM’s empiricism is ultimately shortsighted and that it should integrate some of the rationalist concerns with pathophysiology. I then use this analysis to draw some lessons for research based on the NIMH’s new Research Domain Criteria.

Evidence-based medicine has been a formal component of UK health policy since the early 1990s. This chapter presents a case study that refers to the implementation of clinical guidelines in primary care. The research upon which the chapter is based was a vehicle for understanding something about the policy, organisational and academic context in which it took place, and the manner in which this subsequently developed. The case study serves as a metaphorical vantage point from which to note that a good deal has in fact changed in relation to the changes in EBM, whose discourse has been partly undermined by a consistent political rhetoric in favour of consumer choice and ‘patient-centred’ health care.