Evidence and casuistry. Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches. Journal of Evaluation in Clinical Practice 12, 248-256

Professional judgement in clinical practice (part 3): A better alternative to strong evidence-based medicine

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. Paper three argues that a promising solution is at hand if we can manage several modes of inclusion. A modified original, moderate version of EBM continues though usually overshadowed. As definitively laid out by Sackett in the 1990s, clinical decision making is intended to be person-centered, recognizing and integrating multiple modes of evidence and knowledge that have been marginalized: professional experience, illness narratives, and individual patients' values and preferences. Complementary resources are at hand: interpretative understanding and practice, such as philosophical anthropology, hermeneutical phenomenology, complexity theory, and phronetic practices respond to the major problems and open new possibilities. Phronesis is especially important in regard to public decision making. Within part 3 an additional tone necessarily occurs. 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.

Professional judgement in clinical practice (part 1): Recovering original, moderate evidence-based health care

Evidence-based medicine announced its entry as heralding a new paradigm in health care practices, but it has been widely criticized for lacking a coherent theoretical basis. This paper presents the first part of a three-article series examining the epistemological, practical, and ethical dimensions of strong EBM, as well as considering alternatives that promise potential solutions to chronic conceptual and practical problems. While the focus is on the details of the arguments and evidence in thoughtful debates over the last 30 years, it is worthwhile to keep in mind the overall trajectory of modern thought, because strong EBM continues discredited positivist positions, thus repeating its major assumptions and inadequacies, now transferred to the medical sphere and vocabulary. Part 1 of the series examines the development of strong EBM by clarifying and critiquing its somewhat discontinuous accounts of scientific knowledge and epistemology, evidence, the differences between statistical probability in regard to populations and understanding the health of individuals, and its claims for direct transfer of research findings to clinical settings-all of which raises more questions regarding its application to provider-patient decision making, pedagogy, and policy.

A conditional model of evidence-based decision making

RATIONALE, AIMS AND OBJECTIVES

Efforts to describe how individual treatment decisions are informed by systematic knowledge have been hindered by a standard that gauges the quality of clinical decisions by their adherence to guidelines and evidence-based practices. This paper tests a new contextual standard that gauges the incorporation of knowledge into practice and develops a model of evidence-based decision making. Previous work found that the forecasted outcome of a treatment guideline exerts a highly significant influence on how it is used in making decisions. This study proposed that forecasted outcomes affect the recognition of a treatment scenario, and this recognition triggers distinct contextual decision strategies.

METHODS

Twenty-one volunteers from a psychiatric residency programme responded to 64 case vignettes, 16 in each of the four treatment scenarios. The vignettes represented a fully balanced within-subjects design that included guideline switching criteria and patient-specific factors. For each vignette, participants indicated whether they endorsed the guideline's recommendation.

RESULTS

Clinicians used consistent contextual decision strategies in responding to clearly positive or negative forecasts. When forecasts were more ambiguous or risky, their strategies became complex and relatively inconsistent.

CONCLUSION

The results support a three-step model of evidence-based decision making, in which clinicians recognize a decision scenario, apply a simple contextual strategy, then if necessary engage a more complex strategy to resolve discrepancies between general guidelines and specific cases. The paper concludes by noting study limitations and discussing implications of the model for future research in clinical and shared decision making, training and guideline development.

Treatment considerations for clinicians in applying evidence-based practice to complex presentations in child trauma

Professionals in the child trauma field, eager to bring best practices to children and their families who have suffered from traumatic life events, have developed a number of evidence-based treatments (EBTs) and promising practices available for adoption and implementation into community practice. Clinicians and researchers alike have raised questions about "if, when, and how" these EBTs can be applied to some of the more complex trauma presentations seen in real world practice. The authors take an evidence-based practice approach, including critical appraisal of clients' unique needs and preferences, utilizing applicable trauma treatment core components and current EBTs, and emphasizing monitoring strategies of client progress, particularly when needing to adapt EBTs for select clients.