Epistemology and ethics of evidence‐based medicine: putting goal‐setting in the right place

Abstract

While evidence-based medicine (EBM) is often accused on relying on a paradigm of 'absolute truth', it is in fact highly consistent with Karl Popper's criterion of demarcation through falsification. Even more relevant, the first three steps of the EBM process are closely patterned on Popper's evolutionary approach of objective knowledge: (1) recognition of a problem; (2) generation of solutions; and (3) selection of the best solution. This places the step 1 of the EBM process (building an answerable question) in a pivotal position for the understanding of the whole process, and underscores a few aspects which are often overlooked in EBM courses. First in this step internal evidence (including personal expertise) must be appraised and integrated in the problem. Second, issues of applicability of the possible solution should be anticipated. Third, and possibly more important, the goal of the intervention should be set at this stage (typically by choosing the outcome in a PICO question). Depending whether or not goals depend on the goals of others, and whether they concern others' voluntary behaviour, goals may be classified as self-serving, moral, altruistic or moralistic. Thus, delicate ethical questions must be addressed at this stage, which means that patient preferences and values must be carefully sought, so that empathy, counselling and narrative medicine must be mastered to be able to formulate correctly an answerable question. The need to modify the current description of the EBM process to increase the recognition of implicit assumptions and increase the consistency of this model is discussed.

Mixing it but not mixed-up: Mixed methods research in medical education (a critical narrative review)

“…Wolf (2000) considered that evidence-based medical education would probably develop similarly to evidencebased medicine, where the 'critical appraisal' step (then 'finding best evidence') had made the most progress (oasking relevant answerable questions; ofinding best evidence efficiently, ocritically appraising it; ousing expertise to adapt and apply evidence; oevaluating impact). Better research questions are needed (Schuwirth & van der Vleuten 2004;Shea et al 2004), maybe to altruistic goals (Sestini 2010). The first of Wolf's (2000) 10 lessons from evidence-based medicinesynthesizing evidence is usually more complex and complicated than anticipated -applies particularly when synthesizing non-RCT evidence (from qualitative (Thorne 2009;Broeder & Donze 2010) and/or quantitative approaches).…”

Teaching by (bad) example: what a confused attempt to “advance” EBM reveals about its underlying problems: commentary on Jenicek, M. (2015). Do we need another discipline in medicine? From epidemiology and evidence‐based medicine to cognitive medicine and medical thinking. Journal of evaluation in clinical practice, 21:1028‐1034

“… Insofar as this formula is strictly adhered to, EBM regards the information needs encountered by clinicians in the course of evaluating and treating patients to be self‐evident and inherently related to research designs. A related shortcoming of EBM has been observed to carry over into medical education, starting at the undergraduate level. Maggio et al .…”

A new self‐management intervention for people with severe psychiatric diagnoses

“…Some evidence already suggests that a goal setting and problem solving approach may improve clinical practice and outcomes (Clarke et al, 2009). Goal setting may also help to evaluate the effectiveness of a range of mental health services in meeting the needs of their service users (Sestini, 2010;MacPherson et al, 1999).…”