by Karin Mohn Engebretsen, Better Evidence for a Better Healthcare Manifesto

As a Gestalt psychotherapist, I have seen an increasing number of individuals over the last fifteen years that experience themselves as burned out. This fact has triggered my interest to explore the phenomenon further. Burnout is as a medically unexplained syndrome (MUS). As with other MUS, there is a tendency to assume a narrow perspective to focus on problems related to psyche or soma as pathologies located exclusively within the patient. Research has mainly looked for clear-cut one-to-one relations between cause and effect. These relationships are however difficult to find in complex syndromes. (more…)

Better Evidence for Better Healthcare Manifesto: the CauseHealth Perspective.

The “Better Evidence for Better Healthcare Manifesto” initiative was recently launched by the Oxford Centre for Evidence Based Medicine (CEBM) in collaboration with the British Medical Journal (BMJ).

The manifesto is motivated by a series of problems and blind spots in the implementation of EBM: lack of high quality evidence, systematic research errors, under-reporting of harm, insufficient inclusion of patient’s priorities are some of the issues named by the Manifesto’s promoters. The purpose of the initiative is to spot what could be changed and how, in order to improve the current situation. (more…)

Evidence synthesis in pharmacology

By Elena Rocca

Pharmacology is a complex science that aims to balance harm and benefit of treatments for the individual patient. How should different types of evidence be synthesised in order to optimize this task? Should evidence from randomized trials be prioritized over other evidence, following the EBM model? If not, how can different types of evidence be amalgamated in an alternative way? (more…)

Analogies and High-Stakes Inferences

Samantha Copeland, Thinking about guidelines:

I have been interested for a while in how we justify the move from a single case to conducting research on other patients as research participants. For instance, there have been cases where unexpected (positive) results suggest that a novel approach to treating difficult patients may be found: such as the case in Toronto, Canada where electronic stimulation of a patient’s brain had an effect on his memory that suggested a new method for treating Alzheimer’s might be available; or in Bergen, Norway, when a patient with chronic fatigue unexpectedly recovered from her symptoms while undergoing treatment for Hodgkin’s disease. When a decision is made to start research, researchers must justify why they think the observations made of this particular patient could be repeated in others.

I believe this justification process is most simply expressed as an analogy: one argues that this particular patient is like some other patients in the right ways, and so we can reason that the same effects can be caused by the same treatment approaches. Therefore, it is both correct and ethical for research to attempt to recreate the same results by doing the same things to research participants as was done in this one case with this one patient. (more…)

Standards for Regulation

Stephen Tyreman, Thinking about guidelines:

Following on from the stimulating and highly relevant discussion about guidelines, I want to raise the point that there is a political dimension to the guidelines question that can’t be ignored if the CauseHealth project is to have practical relevance.  I recognise that the previous discussion was around clinical guidelines such as those produced by NICE, but these cannot be divorced from the broader issue of guidelines as they concern professional regulation. (more…)

Challenging Multi-Morbidity

Anna Luise Kirkengen, Thinking about guidelines:

I would like to depart from the most common situation in General Practice, namely: encounters with patients who are categorised as presenting multi-morbidity. This is how it is expressed in the medical language. I would try to change this formulation to something like: a GP’s encounter with a person suffering from what medicine conceptualises as a “number of different diseases”, either simultaneously or sequentially, in the same patient. The concept of “different” diseases does not apply when states of bad health are not strictly separable in terms of etiology, pathogenesis, treatment, and prognosis. Then the question is: on which level does medicine differentiate ethology or pathogenesis. If “two” diseases have a pathological characteristic in common, let us say inflammation, are these “two” diseases still “different” — and due to which criteria? The inflammatory process may affect neuronal cells in one case and connective tissue in the other. This leads to different symptoms and impairments, but both states of illness can be “treated”, in the sense of slowed down or even blocked (though not healed), by the same chemical, namely Cortison, a substance counteracting inflammation — but, in the healthy body — also ignating inflammation. Now —  as inflammation is the pathological property underlying “both types” of diseases, is inflammation to be regarded as CAUSAL? The next question is: what causes the physiological complex termed inflammation? In an evolutionary perspective it is the organisms response to being hurt, being traumatized. Next: does this connection strictly apply to acute, physical wounds/trauma alone? No, we have solid evidence that also experiential hurt or trauma can “cause” inflammation. Is this kind of causal relationship different from the other? …….

and so on and so on.

The nexus of multi-morbidity (as a medical construct or even artefact), causality (as to “level” of origin) and guidelines (specifically designed for each disease) is theoretically highly challenging yet the most common clinical reality in General Practice.

Truth, simplicity, and personalization

Sarah Wieten, Thinking about guidelines:

I was glad to participate in the CauseHealth conference planning meeting October 24th 2016 in London. In the aftermath of the meeting, I was happy to share these brief notes with Sam.

I noticed that the group as a whole seemed very interested in discussing the nature of truth. I was somewhat surprised by this because it can be very abstract work. This is the sort of topic which might be very strictly in the purview of philosophers, and I worry none of us there were the right people to deliver on that topic. If that is what will help the general project of producing better and more useful guidelines, and is a component that others expect we (as philosophers) will be able to talk about, perhaps we should be sure to invite some philosophers that do in fact study that to the conference.

Wrapped up with the hope that philosophers might be able to sort out what truth was the hope that we could say what exactly is bias. There seemed to be uncertainty about how much intentions might matter for whether something was biased or not. It was noted that bias was different than ignorance and that one could be biased without meaning to or without committing fraud, but there was still a bit of a puzzle about why bias was chosen to be the category with which we talked about these various epistemic failures.

I also was excited about a point brought up in the discussion of guidelines, questioning if being “easy to use” was in fact a virtue, as is generally assumed. I wondered if this might fruitfully be linked to the literature in the philosophy of science which questions “simplicity” as an obvious epistemic virtue.

Another question which was raised and I think merits future consideration was, “Is it possible to write guidelines for personalized medicine?” The idea here seems to be that there is something incompatible between insisting that all interventions be indexed to particular individuals and the goal of guidelines, which is to produce widely generalizable population-level advice. However, I wonder how much of this seeming incompatibility might fall away if it becomes clear that the intense personalization promised by personalized medicine is mostly public relations-the best that can be done is to get data from more specific populations and deliver interventions to those specific populations.

Generally it was a vibrant and enjoyable meeting with many important current controversies discussed from a variety of perspectives. I look forward to the upcoming conference.