EBM

Since Evidence-Based Medicine's debut article, the movement has struggled to articulate the relationship between expertise and evidence. In spite of the historical development of three different models of expertise integration in EBM, little is done to flesh out exactly what is involved in such expertise. Given the way in which the nursing literature has embraced the Dreyfus account to describe their own practice, this account has been assumed to fill this gap. I argue that EBM is not compatible with the Dreyfus account of expertise, in light of deep differences regarding the role of intuition and rationalization in medical practice.

Evidence-based medicine (EBM) was announced in the early 1990s as a 'new paradigm' for improving patient care. Yet there is currently little evidence that EBM has achieved its aim. Since its introduction, health care costs have increased while there remains a lack of high-quality evidence suggesting EBM has resulted in substantial population-level health gains. In this paper we suggest that EBM's potential for improving patients' health care has been thwarted by bias in the choice of hypotheses tested, manipulation of study design and selective publication. Evidence for these flaws is clearest in industry-funded studies. We argue EBM's indiscriminate acceptance of industry-generated 'evidence' is akin to letting politicians count their own votes. Given that most intervention studies are industry funded, this is a serious problem for the overall evidence base. Clinical decisions based on such evidence are likely to be misinformed, with patients given less effective, harmful or more expensive treatments. More investment in independent research is urgently required. Independent bodies, informed democratically, need to set research priorities. We also propose that evidence rating schemes are formally modified so research with conflict of interest bias is explicitly downgraded in value.

Electron beam melting (EBM) is an innovative additive manufacturing process in which metal powder is completely melted by a concentrated beam of electrons. In this paper, the effect of powder oxidation, internal porosity and crystallographic texture on the charpy impact energy of Ti6Al-4V specimen fabricated using electron beam melting and hot-isostatic pressing post processing was reviewed. It was observed that the charpy impact energy dramatically decreases in a smooth but rapid fashion due to excessive powder oxidation and has a deleterious effect due to the internal porosity present in EBM Ti-6Al-4V specimen. Crystallographic texture was also found to influence Charpy absorbed energy. However, HIP post-processing significantly increases the impact toughness for specimens in each case.

Evidence-based medicine (EBM), with its evidence hierarchies and emphasis on RCTs, meta-analyses and systematic reviews, sets the model for evidence-based policy almost everywhere, policing no exception. But how closely should policing follow this model? We argue that RCTs can tell you little about what you need to know for real-world practice: will this policy work where and when you implement it? Defending that it will do so takes good theory. For RCTs to play a role in theory development, they must be set into a larger body of knowledge, including local knowledge about the sites of implementation. Unfortunately the standard EBM model generally ignores the other kinds of knowledge needed. An alternative model for evidence-based policing, similar to that of the new movement for 'EBM+' and immanent in the practice of realist synthesis, focuses on the arguments that proposed policing policies will work where and when they are implemented and looks for the evidence needed to support those arguments.

Expertise has been a contentious concept in Evidence-Based Medicine (EBM). Especially in the early days of the movement, expertise was taken to be exactly what EBM was rebelling against-the authoritarian pronouncements about "best" interventions dutifully learned in medical schools, sometimes with dire consequences. Since then, some proponents of EBM have tried various ways of reincorporating the idea of expertise into EBM, with mixed results. However, questions remain. Is expertise evidence? If not, what is it good for, if anything? In this article, I describe and analyze the three historical models of expertise integration in EBM and discuss the difficulties in putting each into practice. I also examine accounts of expertise from disciplines outside of medicine, including philosophy, sociology, psychology, and science and technology studies to see if these accounts can strengthen and clarify what EBM has to say about expertise. Of the accounts of expertise discussed here...

Expertise has been a contentious concept in Evidence-Based Medicine (EBM). Especially in the early days of the movement, expertise was taken to be exactly what EBM was rebelling against—the authoritarian pronouncements about " best " interventions dutifully learned in medical schools, sometimes with dire consequences. Since then, some proponents of EBM have tried various ways of reincorporating the idea of expertise into EBM, with mixed results. However, questions remain. Is expertise evidence? If not, what is it good for, if anything? There have historically been three main models of expertise in EBM. Differences between these models, uncertainty about the difference between expertise as evidence and expertise as a force for amalgamating evidence, and a lack of consensus over whether the older models should be abandoned and replaced by the new, or used in concert, mean that the EBM conception of expertise remains impoverished. There is, however, a wealth of theoretical resources available to enrich EBM's account of expertise. These theoretical resources come from many disciplines including philosophy, sociology, artificial intelligence, computer science, psychology and science and technology studies. Currently, these resources cannot be deployed because of the conflicting opinions within EBM about the role of expertise. In this article, I describe the three historical models of expertise integration in EBM and discuss the difficulties in putting them into practice. I explain how all three accounts leave something to be desired, and lastly suggest that, with some additional clarification from EBM proper, theoretical resources from other disciplines might augment the current EBM account of expertise.

Cet article fait l’analyse de l’usage de la notion de ‘sens clinique’ contre une médecine jugée trop scientifique, en particulier, par opposition à l’Evidence-Based Medicine. Il défend l’importance de dépasser cette opposition en s’appuyant sur l’analyse des multiples significations de la notion de ‘sens’, d’une part, et sur une mise en question de la notion de scientificité impliquée dans ce dualisme à partir de la philosophie des sciences et d’un rappel
de l’esprit de l’EBM, d’autre part.

Introduction: Hypertension is one of the most important health problems which cause significant morbidity and mortality and it can be affected by social factors. Life style modification is an effective strategy to manage blood pressure. This study aimed to determine the effect of educational program of lifestyle modification on adherence to diet and hypertension in hypertensive patients. Materials and Methods: This randomized clinical trial study was done on patients with hypertension referred to Heart clinic at Sayyad hospital of Gorgan in 2015. Patients recorded adherence to diet daily (including 5 subgroups; salt consumption, fatty foods, fruits, fresh vegetables, and low fat dairies), based on the obtained scores they were considered as poor, average and complete adherence. 98 eligible patients with average and low adherence was chosen via convenience sampling and allocated into control and intervention groups using stratified random allocation (n=49). For modifying life style, face to face education took place for intervention group twice a week, over a 2-week period. Each session lasted about 2 hours. Patients in the control group received routine care without any intervention. Educational content relevant to hypertension was including description of hypertension, modifying life style (daily exercise and physical activity, smoking cessation, weight control, improving sleep pattern, decreasing anxiety and stress management), use of prescribed drugs, attend to follow-up appointments, and following recommended diet. Then, adherence to diet was recorded daily for two weeks in both groups. Results: Result showed that education of life style modification was effective on diet adherence (P<0.001). Also the systolic and diastolic blood pressure was decreased after intervention (P<0.001). Conclusion: Educational program for improving diet adherence as a practical life style modification may result to decrease blood pressure of patients with hypertension.

Objectives  The aim of this cross-sectional study was to determine the awareness and attitude of hospital doctors towards evidence-based medicine (EBM) and their related educational needs. Methods  A questionnaire study was performed on a randomly selected sample of 386 hospital doctors from both a teaching hospital and the Ministry of Health general hospitals in Jordan. Attitude towards EBM, best method of moving from opinion-based medicine to EBM, accessing and interpreting evidence and perceived barriers to practise EBM among participants were the main outcome measures. Results  Participants welcomed promotion of EBM and 91.2% agreed that research findings are helpful in daily management of patients. About one-third of respondents (32.7%) thought that the most appropriate way to move towards EBM was by seeking and applying EBM summaries. About one half of participants (47.9%) were unaware of Cochrane database and only 5% used it to help in clinical decision making. More than half (53.7%) reported that they had access to the Internet at their office. Only minority understand the technical terms used in EBM. The major barriers to practising EBM were threat to clinical freedom/judgement, limited resources and facilities, patient overload absence of library in the locally and lack of personal time. Conclusions  Although there is a high support among doctors for the promotion of EBM, there is a deficit in knowledge and skills of EBM. Hence, the time appears ripe for planning and implementing an effective EBM educational programme for both undergraduate and postgraduate doctors.

ObjectiveTo investigate whether the willingness of the general population to undergo a screening test of questionable effectiveness for pancreatic cancer is influenced by the quality and the extent of the information provided.To investigate whether the willingness of the general population to undergo a screening test of questionable effectiveness for pancreatic cancer is influenced by the quality and the extent of the information provided.DesignRandomised study.Randomised study.SettingSwitzerland.Switzerland.ParticipantsRepresentative sample (N=1000) of the general population aged over 20.Representative sample (N=1000) of the general population aged over 20.InterventionsParticipants were randomly allocated into two groups (N=500 each), with one group to receive basic and the other extended quality of information. The information was presented in two hypothetical scenarios about implicit and explicit benefits and adverse events of the screening test. Response rates were, respectively, 80.2% (N=401) and 93.2% (N=466).Participants were randomly allocated into two groups (N=500 each), with one group to receive basic and the other extended quality of information. The information was presented in two hypothetical scenarios about implicit and explicit benefits and adverse events of the screening test. Response rates were, respectively, 80.2% (N=401) and 93.2% (N=466).Main outcome measuresStated willingness to undergo the screening test.Stated willingness to undergo the screening test.ResultsOut of the 401 participants receiving the basic information scenario, 241 (60%) stated their willingness to accept the test, as compared to the 63/466 (13.5%) exposed to the extended one (P < 0.001). After adjusting for respondent characteristics through a logistic regression model, the ‘information effect’, expressed in terms of odds-ratio (OR), shows that provision of additional information was related to a 91% (OR 0.09; 95CI: 0.07 – 0.13) relative reduction in the likelihood of accepting the screening test.Out of the 401 participants receiving the basic information scenario, 241 (60%) stated their willingness to accept the test, as compared to the 63/466 (13.5%) exposed to the extended one (P < 0.001). After adjusting for respondent characteristics through a logistic regression model, the ‘information effect’, expressed in terms of odds-ratio (OR), shows that provision of additional information was related to a 91% (OR 0.09; 95CI: 0.07 – 0.13) relative reduction in the likelihood of accepting the screening test.ConclusionThe quality and the extent of the information provided about the implicit and explicit benefits and adverse events on hypothetical scenarios of a screening test may dramatically change the willingness of people to participate in the testing. This study suggests that provision of full information on the yield of health care interventions plays an important role in protecting the public from being exposed to procedures of questionable effectiveness.The quality and the extent of the information provided about the implicit and explicit benefits and adverse events on hypothetical scenarios of a screening test may dramatically change the willingness of people to participate in the testing. This study suggests that provision of full information on the yield of health care interventions plays an important role in protecting the public from being exposed to procedures of questionable effectiveness.

The ecosystem services concept provides both an analytical and communicative tool to identify and quantify the link between human welfare and the environment, and thus to evaluate the ramifications of management interventions. Marine spatial planning (MSP) and Ecosystem-based Management (EBM) are a form of management intervention that has become increasingly popular and important globally. The ecosystem service concept is rarely applied in marine planning and management to date which we argue is due to the lack of a well-structured, systematic classification and assessment of marine ecosystem services. In this paper we not only develop such a typology but also provide guidance to select appropriate indicators for all relevant ecosystem services. We apply this marine-specific ecosystem service typology to MSP and EBM. We thus provide not only a novel theoretical construct but also show how the ecosystem services concept can be used in marine planning and management.

I argue that a particular conception of mechanisms should be rehabilitated for use in medicine—with one large modification which addresses a main concern of critics. This additional component is the Strevens account of the scope of a mechanism. Because a main critique of the Russo-Williamson Thesis is the worry that mechanisms are so expansive that it is impossible to make a list of all the required parts, the Strevens account, which places the scope of a mechanism neatly between what I call the traditional 'Empty' and 'Boring' accounts, is an important component of making mechanisms useful for medicine.

This study aims to contribute to the development of objective diagnostic standards in Traditional Chinese Medicine (TCM), in order to improve the training of physicians. We devised a questionnaire study to evaluate the accuracy of resident doctors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; diagnostic skills by comparing their assessment of patients with those of their senior supervising physician and the patients themselves. We selected 39 patients with systemic lupus erythematosus (SLE) at Chang Gung Memorial Hospital, Taiwan, between November 1, 2008 and June 30, 2012, and had the resident doctors (R), their senior supervisor (S) and their patients (P) fill out questionnaires before treatment (V1), immediately after treatment (V5) and two months after treatment (V6), in order to record their assessments on the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; condition. The R and S questionnaires covered subjective symptoms, tongue, and pulse, while the P questionnaires only included general symptoms. We then compared the assessment records to determine the level of agreement between them. The agreements of inquiry during the study for P and S were 0.78 (V1) to 0.84 (V6) and 0.87 (V1) to 0.94 (V6) for R and S, respectively, the agreements between R and S for tongue diagnosis and pulse diagnosis were 0.87 (V1) to 0.90 (V6) and 0.91 (V1) to 0.95 (V6), respectively. All the above agreements improved with time from V1 to V6. The results show that the patient input was feasible and effective and that the questionnaire method provided an objective assessment standard to determine how successfully the resident doctor was trained. Furthermore, it facilitated a training process that could help resident doctors improve their skills.

The effects on timber supply incurred by implementing an ecosystem-based management strategy were evaluated in an eastern Canadian boreal forest management unit. Standard linear programming was used to test the effects of four key policy issues: (1) aim for a targeted forest age structure inspired by natural fire regime and forest dynamics (multi-cohort approach), (2) agglomerate harvest blocks in operating areas to reproduce natural disturbance patterns at the landscape scale, (3) maintain cumulated clearcutting and natural disturbance rates inside the historical range of variability, and (4) exclude from harvest areas of potential interest to aboriginal people. The targeted forest age structure was achieved with a minimum reduction of periodic timber supply, but only after 50 years. Compared to a “business-as-usual” scenario, inclusion of the first three policy issues resulted in a 3% to 11% reduction in planned timber supply and a restoration period requiring that 43% to 67% of t...

Objectives  The aim of this cross-sectional study was to determine the awareness and attitude of hospital doctors towards evidence-based medicine (EBM) and their related educational needs. Methods  A questionnaire study was performed on a randomly selected sample of 386 hospital doctors from both a teaching hospital and the Ministry of Health general hospitals in Jordan. Attitude towards EBM, best method of moving from opinion-based medicine to EBM, accessing and interpreting evidence and perceived barriers to practise EBM among participants were the main outcome measures. Results  Participants welcomed promotion of EBM and 91.2% agreed that research findings are helpful in daily management of patients. About one-third of respondents (32.7%) thought that the most appropriate way to move towards EBM was by seeking and applying EBM summaries. About one half of participants (47.9%) were unaware of Cochrane database and only 5% used it to help in clinical decision making. More than half (53.7%) reported that they had access to the Internet at their office. Only minority understand the technical terms used in EBM. The major barriers to practising EBM were threat to clinical freedom/judgement, limited resources and facilities, patient overload absence of library in the locally and lack of personal time. Conclusions  Although there is a high support among doctors for the promotion of EBM, there is a deficit in knowledge and skills of EBM. Hence, the time appears ripe for planning and implementing an effective EBM educational programme for both undergraduate and postgraduate doctors.

Evidence-based health care (EBHC) has consistently been attacked by opponents for being perniciously reductive. Although these attacks are overwhelmingly framed as critiques of evidence-based medicine, they standardly target the research wing of EBHC upon which evidence-based medicine is dependent, and increasingly extend to adjacent health care disciplines, such as nursing. One of the most persistent forms this line of attack has taken is the allegation that EBHC, with its emphasis on the hierarchy of evidence, grounded in the use of randomized controlled trials, and the clinical guidelines developed on their basis, fails to recognize the patient as the complex self she is, treating her instead as merely a quantifiable, medical-scientific object. By reducing the patient to certain quantifiable dimensions, the patient as self is allegedly ‘erased’. In short, the complaint is that an evidence-based approach to health care has no room for the self. Contrary to this persistently held view, it is argued here that EBHC does have room for the self. Review of these critiques suggests they can be categorized into two groups: soft critiques and strong critiques. Soft critiques tend to take a more measured tone grounded in empirical concerns about the dangers of an evidence-based approach to health care, whereas strong critiques tend to make sweeping claims grounded in theoretical commitments to anti-foundationalist philosophical frameworks. While both soft and strong critiques ultimately fail to make the case that EBHC has no room for the self, the empirical concerns of soft critiques nevertheless present a challenge EBHC advocates would do well to take seriously and address.