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…)

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.

Guidelines in situ

Fiona Moffatt, Thinking about guidelines:

My research interest lies predominantly in the notion of knowledge translation, exploring the complex, non-linear relationship between what is ‘known’ and what is subsequently ‘done’. I understand evidence based guidelines and evidence based policy as key rhetorical devices (or technologies) bridging the liminal space between empirical knowledge and clinical practice. My methodological perspective is however, strongly influenced by the sociological discipline of STS, whereby all technologies are contingent, i.e. rejecting technological determinism.

Science and technology are social activities, and the agents (researchers, technologists, healthcare professionals, patients) are members of communities trained in certain practices and with immanent virtues, values and beliefs. Consequently, the resultant interpretations of knowledge are complex and various. Claims, theories, facts and artefacts have very different meanings to different audiences.

Evidently, I am therefore interested in the social construction of knowledge. At a crude level we can ask ourselves,

‘do evidence based guidelines/policies normalise in practice?’ and

‘what are the sociocultural moderators?’

Much work has been undertaken in this field – in my own work I have developed understanding about the influence of governance arrangements, power, neoliberalism, identity, prevailing logics of professionalism, compatibility with existing practice etc. However, what I believe remains under explored is an exposé of the ways in which ‘evidence’ is cognitively appraised. What can we say about evidential pluralism? What are the various epistemological and ontological assumptions between professions, and what are the resultant power dynamics produced? How can healthcare professionals navigate their ultimate position – in what ways do they modify or re-interpret the evidence to match their own philosophical assumptions and reconcile this with the perceived needs of their healthcare context? Could a dispositionalist approach help us to better understand this process? And could this knowledge then impact upon a re-conceptualisation of EBM?

Challenges to come

Roger Kerry, Thinking about guidelines:

My take home thoughts:

What is the real world, clinical role of guidelines? (provoked by Jeremy Howick’s suggestion that guidelines shouldn’t make recommendations, Sarah Weiten’s talk on values and mechanisms, and Sieste Wieringa’s talk on induction and reasoning)

Can a more holistic conceptualisation of causation really be integrated into guidelines which take population data as central to their development? (provoked by Stephen Mumford and Rani Anjum’s comments of the background philosophy of causation, as well as Karin Engebretsen and Elena Rocca’s talks on diagnosis and bench study data)

Can a guideline and evidence-based system truly move beyond hierarchies? (provoked by NICE’s Beth Shaw review of multiple evidence sources and their integration into guideline development. A beautiful talk, but I still think there is hierarchy at the core when push comes to shove. Show me I’m wrong!)

What is the future of implementation, governance, abuse-control strategies for guidelines? (provoked by Fiona Moffatt’s, Mary Chambers’, and Samantha Copeland’s highly informed musings on things from deep sociological concerns to PPI and the reality of the clinical shop-floor, and analogical thinking)

The planned conference for next year should turn out to be a hot-bed of challenge, controversy, and progress for all.