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The guidelines challenge-Philosophy, practice, policy
Article in Journal of Evaluation in Clinical Practice · July 2018
DOI: 10.1111/jep.13004
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Received: 28 May 2018
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DOI: 10.1111/jep.13004
CONFERENCE REPORT
The guidelines challenge—Philosophy, practice, policy
Rani Lill Anjum PhD, Research Fellow1 | Samantha Copeland PhD, Postdoctoral Fellow2
Roger Kerry FMACP MCSP MSc PhD, Associate Professor3 |
|
Elena Rocca PhD, Postdoctoral Fellow2
1
Principal Investigator CauseHealth Project, Director Centre for Applied Philosophy of Science, Norwegian University of Life Sciences, Ås, Norway
2
CauseHealth Project, Centre for Applied Philosophy of Science, Norwegian University of Life Sciences, Ås, Norway
3
Division of Physiotherapy and Rehabilitation Sciences, University of Nottingham, Nottingham, UK
Correspondence
Samantha Copeland, PhD, Postdoctoral Fellow, CauseHealth Project, Centre for Applied Philosophy of Science, Norwegian University of Life Sciences, Postboks 5003,
NMBU 1433 Ås, Norway.
Email: samantha.marie.copeland@nmbu.no
Funding information
Research Council of Norway
K E Y WO R D S
causation, clinical reasoning, complexity, health care guidelines, person‐centred health care, policy
1
|
I N T RO D U CT I O N
emerged from these events. A review of the introductory statements
from CauseHealth Principal Investigator Rani Lill Anjum can be found
In Oxford, UK, on the 3rd and 4th of October 2017, the CauseHealth
within this issue of this journal.1,2 During these introductory
group held a conference to tackle what they called “guidelines chal-
statements, Anjum laid out the guidelines challenges that CauseHealth
lenges.” New approaches to evidence and medical knowledge, as well
had marked as most important and urgent and how thinking of
as how to use that knowledge in practice, present specific challenges
causality from the perspective of dispositionalism—a key component
for current evidence‐based methods for developing and implementing
of the CauseHealth approach3—can frame solutions to those
guidelines. Because the conference aimed to produce both theoretical
challenges. In the following paper, we give a brief overview of the
and practical proposals for solutions to these challenges, it was titled
talks presented, along with some thoughts on theoretical and practical
“The guidelines challenge—Philosophy, practice, policy,” and speakers
proposals for going forward from here.
from diverse disciplines and professions were invited to speak and
attend.
The challenges themselves arose during discussions held at past
2
|
TALKS AND CENTRAL ISSUES
activities with CauseHealth and the broader network of collaborators
involved in that project. For instance, in Aas, Norway, in January 2016,
a workshop, “N=1, Causal Reasoning and Evidence for Clinical
Practice” was held, giving a platform for many speakers to raise issues
regarding the translation of knowledge and evidence between popula-
2.1 | Trish Greenhalgh, Desperately seeking
personalization: how evidence‐based guidelines
sometimes produce non‐evidence‐based care
tions, clinical guidelines, and individual, person‐based care. Bringing
Trish Greenhalgh, a general practitioner and professor of primary
these broader questions to bear on the issue of guidelines specifically
health at Oxford University, gave the opening keynote of the confer-
was the task of a workshop held in London later that year, “Thinking
ence. Greenhalgh shared her experience as a patient to deliver a fasci-
about Guidelines.” To that workshop, CauseHealth invited speakers
nating insight into the operationalization of evidence‐based guidelines
from philosophy and diverse fields of medical practice to assess what
in typical clinical decision making. Paradoxically, Greenhalgh suggested
the key questions facing guidelines developers and those who use
that the use of evidence‐based guidelines sometimes produced non‐
them might be and what philosophy could offer in the efforts to
evidence‐based care. The talk struck a chord that would play through
resolve them. The themes for the “Guidelines Challenge” conference
the rest of the conference, that the problem of translating data from
J Eval Clin Pract. 2018;1–7.
wileyonlinelibrary.com/journal/jep
© 2018 John Wiley & Sons, Ltd.
1
2
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ET AL.
populations to individuals is far from resolved. Greenhalgh appealed to
of evidence relevant to clinical practice, and not the other way around.
her ongoing campaign for real evidence‐based medicine to raise con-
This was also addressed by the next keynote, who offered an alterna-
cerns that evidence derived from population data should be contextu-
tive approach to guidelines developers working within the EBM
alized within the individual clinical situation. This is different from
framework.
personalized medicine, which is focussed but limited in its application.
Rather, “real” EBM relies on the other features of clinical practice, such
as communication, expert judgement, shared decision making, and
multiple sources of evidence. Again, paradoxically, “real” evidence‐
based medicine relies on the factors that have typically been
2.3 | Mike Kelly, Empiricism, reductionism, linearity
and value neutrality in guideline development: a realist
alternative
deemphasized by the advent and development of the EBM movement.
Professor Mike Kelly, of the Department of Public Health and Primary
An interesting conclusion Greenhalgh presented was that perhaps if
Care at Cambridge, delivered the second keynote. Kelly pointed out
we practice individualized and patient‐focussed “real” evidence‐based
that the EBM ideal of causality we find in the RCT, for instance, is very
medicine, in many cases, we do not need “more evidence.” Uncer-
different from the kind of causality we see in the social sciences, as
tainty is inherent in clinical practice and to perform more controlled
they try to understand human behaviour. Kelly revisited the traditional
trials, in an attempt to reduce that uncertainty, will not improve clinical
problems with establishing causal associations and external validity
decision making. Greenhalgh signed‐off her talk with the suggestion
and spoke of how EBM tried to deal with these, with some but limited
that returning to traditional clinical method and adopting a less com-
success.6 As a way towards resolution for many of the limitations of
prehensive use of EBM will lead the way towards best clinical
EBM, Kelly proposed a better consideration of mechanisms and mech-
practice.4
anistic science.7,8 He reinforced previous suggestions that scientific
The keynote led directly into the first thematic session,
“Challenges
in
Development—Integrating
Knowledge
through
Collaboration.”
data are not value‐neutral, and that other factors (social values, theory,
clinical judgement, expert opinion, experience, observation, etc) also
play important roles in the development and implementation of
EBM. In conclusion, Kelly stated that the way interventions work in
2.2 | Beth Shaw and Sietse Wieringa, Appraising and
including different knowledge in guidelines
different sectors of the population is not well understood. This
remains a fundamental problem, especially for those working to apply
the principles of EBM and public health. To highlight this, Kelly reiter-
Beth Shaw, a guidelines developer with NICE in the United Kingdom,
ated that knowing the cause (in a linear, regularities sense) of a disease
and Sietse Wieringa, a general practitioner and scholar at Oxford and
does nothing to help understand how to prevent that disease.9 There
the University of Oslo, are members of the Guidelines International
is a traditional focus on “what” questions in EBM, and not enough on
Network (GIN) AID Knowledge Working Group. Their talk focussed
the “hows,” and this is a fatal flaw.
on appraising and including different types of knowledge in clinical
In both talks and discussions throughout the conference, this idea
guideline development. Following a brief history of guideline
arose: More focus needs to be placed on how interventions work and
development, and a summary of the group's purpose,5 Shaw and
less on what interventions are, statistically speaking, effective. Other
Wieringa discussed the inclusion of multiple sources of evidence in
speakers chose to emphasize these as epistemic issues as well,
contemporary evidence‐based guideline development. There was
questioning the concepts in play when we talk about “evidence” in
explicit acknowledgement that this was a difficult and inconsistent
relation to medicine. In this vein, the theme of “The Challenge of
process. Scientific values are often balanced against social values,
Implicit Knowledge” was taken on by two groups of speakers. The first
with an awareness of the complexity and uncertainty of clinical
pair tackled the role that implicit knowledge plays in how we conceive
decision making. But what is not yet known is exactly how clinicians
and define what counts as evidence when developing guidelines.
make the inferences they do: the interaction between experience,
tacit knowledge, and evidence from research remains within a black
box. What we do know is that there are more kinds of reasoning
being used than frequentist reasoning, so guidelines developers
2.4 | Elizabeth Matovinovic, Cathedral and bazaar:
GRADE as a scaffold for implicit knowledge
need to consider a broader range of evidence than from randomized
Elizabeth Matovinovic is a consultant epidemiologist, a member of
controlled trials, or RCTs. Understanding how these inferences are
GIN, and leads the Philosophy of GRADE project group. She began
made and how different kinds of knowledge interact is important
with Greenhalgh's cathedral and bazaar analogy, using it to compare
if guidelines are to support such clinical decisions, Shaw and
the world of rational choices (the cathedral) with the implicit judge-
Wieringa argued.
ment of the logic of care (the bazaar). Matovinovic presented the
These first two talks pointed to the variety of evidence that could
GRADE Guideline Development Framework to show how guidelines
be useful to clinicians and, therefore, should be considered within
could explicitly map the complexities witnessed in the bazaar, if they
evidence‐based guidelines. The question remains whether it is possi-
considered the up and down grading of evidence based on risk of bias
ble to incorporate all relevant types of evidence into a guideline, how-
and balanced benefits and harms. Further, GRADE is only relevant for
ever. Perhaps, guidelines cannot accommodate all aspects of practice
clinical decisions that require the formal assessment of best evidence.
but rather provide only a partial guide for clinicians. A returning theme
Some strong recommendations and most good practice statements
at the conference was that EBM needs to adapt to the multiple types
should not be “GRADEd” because certainty and high confidence are
ANJUM
3
ET AL.
already implicit without requiring formal research. Where GRADE
will work), arguing that attempts to make mechanisms all‐inclusive and
makes weak recommendations, Matovinovic argued, these serve as
thus safely generalizable, make them so “large” that they become
explicit scaffolding that helps reduce the implicit persuasion that
impossible to manage.11 This assumption, she suggested, comes from
occurs during shared decision making. In her conclusion, Matovinovic
equivocating evidence from mechanisms to an ideal kind of evidence.
stressed that the understanding and progress of EBM is influenced
One possible source of this high ideal is the claim that an RCT can
by the unresolved epistemological discourse surrounding the nature
consider all confounders. Not only is this a potentially suspect claim,
of evidence.
but even if it were not, mechanisms should be assessed according to
their own standards. Wieten concluded by saying that philosophy
2.5 | Karin Engebretsen, Suffering without a medical
diagnosis
can help stipulate the scope of mechanisms by looking to how many
factors are needed, which might be specific to what they are being
used as evidence for.
A Gestalt psychotherapist and PhD student at the University of Oslo,
Karin Engebretsen delivered a commentary on medically unexplained
symptoms, presenting her findings from her existential phenomenology research investigating the lifeworlds of a number of sufferers of
2.7 | Elena Rocca, Guidelines and evidence of
mechanism: looking for a missing link
“burnout.” In the failure of evidence‐based medicine to provide a
Elena Rocca, pharmacist and member of the CauseHealth project
meaningful explanation and diagnosis, patients are left “naked in the
team, highlighted that by “causal mechanism,” one can mean two
eye of the public.” Engebretsen called for a new framework for
different things. The first is a generalized model of mechanism, which
genuine person‐centred health care. In this new paradigm, scientific
has to satisfy the requirements of reproducibility, regularity, and
evidence might include patient‐based evidence where the person is
confirmation, and is typically the aim of scientific research. The second
understood as an agent who is in constant interaction with his or
is the mechanism in situ, which is the single process that is happening
her environment, aware of phenomena such as the experience of
in the specific patient, and is investigated during the clinical encounter.
bodily sensations in response to internal and external interacting
While guidelines have so far mainly focused on the information flow
factors. Additionally, she made an appeal that our medical model
from scientific research to the clinical encounter, Rocca urges that
requires a rethink, specifically that the positivist approach to health
the opposite direction of information flow also needs improvement.
is no more scientific than a phenomenological one.10
How can the investigation of the mechanism in situ contribute to
Thus, the speakers in the second session raised the issue of
the understanding of a generalized model of mechanism? Guidelines
implicit knowledge from the perspectives of guidelines developers,
can help by building a culture in which the clinician is not only a user
practitioners, and patients. GRADE, the go‐to resource for guidelines
of the best available evidence but actively contributes to making this
developers in search of a standard methodology, has recently had to
evidence better. In such a culture, clinicians take responsibility for
make space for certainty that cannot be made explicit, but nonetheless
the communication of details from the clinical encounter, especially
grounds confident claims about effectiveness. Patients need
with patients that are seen as “outliers” in respect to the statistical
approaches that take into consideration the implicit aspects of their
majority. Such information is otherwise lost in population studies or
condition, particularly in cases of medically unexplained symptoms.
via experimental isolation.12
And, in an echo of comments made above, practitioners need
The final session of day one was the first of two sessions on the
guidelines that do not neglect relevant types of evidence in favour
theme of “Challenges in Practice” and considered the idea of “Keeping
of being “scientific” in an exclusionary sense.
the Person Whole.” This challenge is particularly important for the
As Kelly noted in his talk, summarized above, one kind of evidence
CauseHealth project, which has worked towards reconciling how we
that is frequently neglected is evidence of mechanisms. This raises the
think about causality in general with how we treat individual patients.
question of how and when to incorporate evidence of mechanisms
CauseHealth has found, through its work with both philosophers and
into guidelines specifically, giving the theme for the third session,
practitioners, that the first step in applying causal knowledge must
“The Evidence Challenge—Working with Mechanisms.”
be to address the person as a whole. The two last speakers on the first
day of the conference, therefore, spoke of how this can be done—and
2.6 | Sarah Wieten, Manageable mechanisms: how
confounders make amalgamation difficult
Supported by the Departments of Philosophy at Durham University
and Indiana University of Pennsylvania, Sarah Wieten presented an
why it must be done—in clinical practice.
2.8 | Anna Luise Kirkengen, From wholes to
fragments to wholes—is something lost in translation?
argument on how confounders make understanding a complete mech-
Professor in General Practice, Anna Luise Kirkengen, from the Norwe-
anism difficult. For instance, we know that sulphur on a struck match
gian University of Science and Technology, looked at the translation
will light—unless it is under water. But how many such factors must
from wholes to fragments to wholes and wondered if our present scien-
we consider? Wieten responded to the Russo‐Williamson Thesis (that
tific framework allows important information and knowledge to get
probabilistic methods are needed to make up for the weaknesses of
“lost in translation.” For instance, existential hardship can result in a
mechanisms as evidence) and to Jeremy Howick's position (that mech-
phenomenon called inflammation, affecting different bodily tissues
anisms are too difficult to identify and to predict how and when they
and structures and presenting as clinically different “diseases.”
4
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ET AL.
However, these cannot be fully understood on the level of bodily
brief summary of the notion of potential outcomes equations,
fragments since they originate from the person's lifeworld. Kirkengen
sketching out ways (for example, econometric causal modelling, causal
drew on powerful patient narratives to develop and highlight the
Bayes nets and process tracing) of how to do such equations. The
rhetorical and authoritative morphism of a strict and guideline driven
purpose of this was to show how RCTs sat somewhere in the middle
interpretation of EBM. Should guidelines use patient stories in their
between the general and the particular and examined one (and only
development and implementation?13
one) aspect of the causal network. Additional knowledge is required
to move beyond the study population. The different approaches to
2.9 | Brian Broom, Getting real in whole person‐
centred health care: the challenges in actually doing
this stuff
A Consultant Physician in Clinical Immunology and Psychotherapist
causal modelling could each have a role in developing knowledge of
particular causes. Cartwright demonstrated some examples of a range
of causal theories and models and proclaimed that it is necessary for
guideline developers not to ignore these models, as they are “good
ways to learn what we need.”15
from Auckland City Hospital, Brian Broom, presented the third key-
In the next session, there was a return to the theme of
note. In his work, Broom emphasizes a whole‐person perspective in a
“Challenges in Practice,” with a focus on the question “Where do
person‐centred understanding of causation of physical disease (of all
Values Come From?” The aim was to address not only whence values
kinds) and of the provision of health care.14 Styling himself as a clinical
arise but also how we might take them up via guidelines effectively.
phenomenologist he pays very close attention to the subjective
The challenge here is to take values as a kind of evidence in their
“stories” of patients presenting with physical disease. In his whole‐per-
own right, without changing them to make them fit into a restrictive
son model, clinicians of all kinds can actively seek the emotional and
approach to decision making.
relational stories of the sick person's lived (historical and present)
experience. These stories are actively and empathically uncovered in
ordinary clinical settings. Important connections between the stories
and the illnesses emerge in ways that are “true” both for the patient
2.11 | Minna Johansson, “Informed Choice”—no
panacea for ethical difficulties
and the clinician as they work together. The accounts provided by
Minna Johansson presented her work and theories from her experi-
Broom of some of these therapeutic encounters revealed a stark con-
ences as a Swedish general practitioner and PhD student at the
trast between biomedical disease models of causation and treatment
University of Gothenburg. As others had, this speaker juxtaposed
and the whole person model that considers and values the real‐life
the linear, biomedical, positivist assumptions of clinical guidelines
complexity of factors (physical and subjective) in the lives of persons
against the messy, uncertain real‐world of clinical practice. Johansson
that influence the onset, course, and outcomes of disease in people
presented a number of case studies that eloquently demonstrated
receiving health care. The whole person model is nondualistic, unitive,
how the inclusion of shared decision making and informed choice
multidimensional, multifactorial, and relational. Broom concluded with
could exist in‐line with a judicious adherence to evidence‐based
encouraging messages about listening (and principles of listening) to a
guidelines. Cautions were raised about potential harms of information
person's story as an essential and powerful element of the skill sets of
giving and transference of responsibilities.16 Johansson's conclusions
the “good clinician.” At present, it is difficult to see how the existing
were again focused on highlighting the limitations of any singular
dualistic and positivist structure of EBM and clinical guidelines could
approach to decision making and that a complex real world calls for
relate to and facilitate a truly whole‐person approach to health care.
the intellectual pursuit of the inclusion of multiple sources of evidence
Concluding the day with close attention to the role of patient
and information, with no panacea from either side.
stories in understanding how the evidence of illness and the effectiveness of interventions interact, provided one way to understand the
practical suggestions raised by Greenhalgh in her opening salvo. The
evidence that guidelines can take up and convey in the form of guid-
2.12 | Bill Fulford and Stephen Tyreman, Choosing
together: from informed choice to dialogue
ance is limited, in part because of the form that such guidelines must
Shared decision making was the central concern here. In osteopath
take. Further, as other speakers on the first day suggested, different
Stephen Tyreman's absence, Bill Fulford—of the Department of
kinds of evidence—the hows and the whys, and that which cannot
Philosophy,
University
of
Warwick—developed
an
argument
be made explicit—are relevant to clinical decision making and need
supporting shared values and value‐based practice as a central part
to be addressed, if guidelines are to be effective. But how shall they
of best practice. Case studies were again used, this time to show
be addressed? To this question turned the speakers of Day Two.
how patient values—listening to what matters—should inform shared
decision making in the context of evidence‐based practice. Listening
2.10 | Nancy Cartwright, What evidence should
guidelines take note of?
was again highlighted as a key clinical skill, and this was put in the
context of the Montgomery Supreme Court Ruling (2015) whereby
consent requires “choosing together based on values and evidence.”
Durham University Professor of Philosophy, Nancy Cartwright, gave
Because values often present as implicit in decision making about
the opening keynote. Her introductory statement proposed that there
when to apply guidelines and how, the following session returned to
is a growing concern towards the particular, whilst guidelines must be
the “Challenge of Implicit Knowledge” theme. This pair of speakers
concerned with the general. To explain her position, Cartwright gave a
addressed
the
role
that
implicit
knowledge
plays
in
the
ANJUM
5
ET AL.
implementation of guidelines, that is, how the broader context in
strategic reasoning. Her argument was essentially about expertise
which both practitioners and patients work and live determine
and how reasoning strategies identified in experts related to guideline
guideline effectiveness.
use. Typically, such reasoning strategies are thought of in terms of
searches for relevant causal processes, in‐line with considerations of
patient values and preferences. The idea is to predict the outcome,
2.13 | Fiona Moffatt, The new “normal”?
Professional sense‐making and evidence based
guidelines
and then work towards it. Copeland described an alternative kind of
strategic reasoning, effectual reasoning, as a “non‐recipe,” goal‐
focussed, collaborative process. She argued that in the clinic, not just
Physiotherapist at the University of Nottingham, Fiona Moffatt, took
the intervention but the reasoning process itself constitutes the end
the perspective of clinical guidelines further, discussing the role of
goal of the encounter between patient and clinician. The same inter-
the clinician in evidence‐based, shared decision making. She asked
vention can give variable results because of the reasoning process.
“what is it that makes a clinical guideline meaningful to a healthcare
In conclusion, a reasoning strategy which is mindful of values, prefer-
professional?” Moffatt constructed her argument in a wider frame-
ences, resources, environments, and networks is a feature of exper-
work of science, technology, and society, specifically drawing on her
tise. Experts under an effectual model look towards influencing the
own work with normalization process theory. Using two separate
outcome rather than predicting the outcome. Further, in this model,
guidelines as case studies to highlight the “chasm” between guidelines
guidelines become useful tools for reasoners who are working out
and practice, she presented data regarding how and why practitioners
their goals, rather than predetermined pathways to predicted ends.
show resistance to enforced guidelines.17 Moffatt claimed that there
is neither a common philosophy nor vocabulary between guidelines
and practice. To better understand the chasm between guidelines
and
practice,
Moffatt
proposed
we
need
to
consider
the
performativity of guidelines from a professional perspective.
2.16 | Alex Broadbent, Judges or robots? Medical
expertise in the guideline era
Philosopher of Epidemiology at the University of Johannesburg, Alex
Broadbent, continued the focus on expertise in a guideline era, won-
2.14 | Mathew Mercuri, When guidelines don't
guide: examining the role of patient context in
guideline adherence
dering whether clinicians should behave as robots (following guidelines) or as judges (using the guidelines with judgement in relation to
context). Broadbent discussed the role of guidelines, particularly in
relation to duty of care, control, and to overt and covert goals. Upon
Mathew Mercuri, from the Department of Medicine at McMaster
identifying what guidelines were, a thesis on “what is medicine” was
University, continued to examine the role of patient context in guide-
presented. Broadbent proposed that the core business of medicine
line adherence, demonstrating cases of when “guidelines don't guide.”
was not curative, but rather one of enquiry (regardless of the curative
Mercuri first presented data on nonadherence to guidelines, summa-
outcome).19 This is problematic for the position of guidelines which
rizing physician and resource related barriers to adherence. He raised
now may “short‐cut” the core business of medicine and accounts for
the issue of patient related barriers, in particular those related to the
much of the ambivalence felt towards EBM. The clinician's role, there-
patient's “non‐medical” context. Presenting his own data next, Mercuri
fore, is neither one of robot nor judge but rather as part of a wider
identified how these contextual variables could influence physicians'
network of stakeholders interested in a process of medical enquiry.
decision making despite the availability of a high quality, evidence‐
based guideline.18 That is, the presence of these variables moved them
away from guideline adherence. This knowledge should now be used
to develop frameworks in which to educate clinicians as to when it
is appropriate to not adhere to guidelines.
2.17 | Hálfdán Pétursson, The validity and relevance
of guidelines for prevention of cardiovascular disease
for general practice
The final two sessions of the conference looked closer at
Icelandic physician Hálfdán Pétursson presented data from his
guidelines themselves, at what they are about and what kind of thing
research on the validity and relevance of cardiovascular disease
they are. The first of these sessions addressed the theme of “Using
(CVD) prevention guidelines in general practice.20 His analyses indi-
guidelines,” taking a philosophical approach to understanding the
cate that guidelines might define the majority of the Norwegian pop-
kinds of expertise needed to implement guidelines effectively in the
ulation at increased risk of CVD. If the guidelines on management of
clinical context. In the final session of the conference, the speakers
high blood pressure were to be followed strictly, the workload would
asked “What is a Guideline” by looking closely at some of their practi-
demand more than the whole GP workforce for that task alone. He
cal and theoretical consequences.
addressed some limitations of statistical approaches to risk data and
how these are translated to clinical practice. Cautions were left with
2.15 | Samantha Copeland, Effectual reasoning in
the clinical context: thinking strategically about
guidelines
the audience regarding the likely gross over‐estimation of risk in clinical guidelines. Pétursson regarded the three most important factors
limiting the validity and relevance of guidelines to be: “silo vision,”
fragmenting patients by disease‐specific guidelines that are difficult
Samantha Copeland, a philosopher and member of the CauseHealth
to apply to the multimorbid real‐life individual; “zero vision,” striving
project team, suggested in her talk that clinical reasoning is a kind of
to eliminate morbidity from specific diseases without taking the whole
6
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person
into
account;
and
“Vulgar
Cochranism,”
expressing
“aggressively assertive,” “presumptuous,” and “arrogant” applications
of data, oft‐seen in preventive medicine. He regarded these factors
as imperfect and problematic strategies to minimize complexity and
uncertainty in clinical practice.
3.5
ET AL.
Context matters
|
Transparency, communication, and shared decision making are in line
with most clinical guidelines, yet they are not equally appropriate in
every situation.
3.6
Guidelines, not tramlines
|
2.18
Stephen Mumford and Rani Lill Anjum,
Philosophical argument against evidence‐based policy
It is sometimes inappropriate to adhere to guidelines. Example of situ-
The final presentation of the conference was given by Durham
acknowledged and part of the medical education.
|
ations in which guidelines ought to be discarded should be officially
Professor of Philosophy and member of the CauseHealth team, Stephen
Mumford, who gave his and Anjum's philosophical argument against
21
evidence‐based policy.
They propose that evidence‐based policy is
analogous to a rule utilitarian philosophy. Evidence‐based policy aims
at the rule that will produce most benefit for most people, if a single rule
has to always be followed. However, this is problematic because someone whose aim is to maximize utility will always be motivated to break
such a rule in the cases where more benefit can be achieved in doing so,
3.7
Challenging positivist ideals
|
What counts as “scientific” is too narrowly defined within EBM, and
alternatives to the positivist and dualistic ideals should be welcomed.
For instance, clinical choice should be guided by methods that
embrace patient narratives and embodied lived experiences as keys
for investigating causes and effects.
such as when there is good evidence that no benefit would follow in an
individual case from following the general rule.
3.8
Clinical judgement upgraded
|
Evidence from different sources and methods often diverge, and this
leaves a fundamental role to clinical judgement. This role needs to
3
L E S S O N S L E A RN E D
|
Overall, the speakers raised some important themes, which we would
like to highlight and propose lessons learned from the conference.
be acknowledged and valued.
3.9
Epistemic humility is crucial
|
Uncertainty is not eliminable from the process of decision making but
should instead be the basis for epistemic humility. The lack of certain
3.1
|
No statistically average patient
predictions reflects the reality of the clinic.
The idea of the average or standard patient is a statistical artefact: in
clinical reality, a normal, standard, or average patient does not exist.
3.10
|
Understanding causal mechanisms
To assist the best and most rational clinical choice for single patients,
3.2
|
“Evidence” expanded
it is important to know the causal mechanisms underlying statistical
correlations. Indeed, knowing what happens to other patients is useful
The meaning of “evidence” needs to be expanded, not restricted to
for the clinical management of the single patient, insofar as we also
evidence from experiments and controlled setups. In addition, it
know why it happened, that is, which properties were involved.
should include evidence from the specific patient who is supposed
to benefit from the guideline.
3.11
|
Evidence from clinic to research
The clinical encounter gives a good chance to investigate causal
3.3
|
More types of evidence
Guidelines need to include “more evidence,” but not in the sense of
“more repetition of the same type of evidence.” Rather, we need
multiple types of evidence. In particular, the epistemic status of
evidence from single cases needs to be upgraded.
mechanisms in real‐life complexity. Guidelines should make the most
of this opportunity. For instance, guidelines should ensure that significant clinical observations are done in a patient‐centred way, that they
are analysed qualitatively, and that results from the qualitative analysis
feedback to research with new hypotheses.
3.12
3.4
|
Patient values included
|
Broader guidelines
The clinician is part of a bigger network of enquiry and research, aimed
Evidence should not only include scientific values but also social
at understanding the causes of illness and healing. Guidelines aimed
values, and the latter are clearly changing from one context of applica-
only at one outcome (the cure) risk suffocating the knowledge‐build-
tion to another. Listening and evaluating the specific patient with her
ing process of the medical enterprise. Therefore, guidelines should
set of values is a basic skill of clinical practice. Just as we say that there
aim at more outcomes than only the cure. For instance, they should
is no intervention that is universally valid, there is also no value that is
guide how to report, record and communicate observations with the
universally relevant.
rest of the medical community.
ANJUM
7
ET AL.
ACKNOWLEDGEMEN TS
The CauseHealth project and the Guidelines Conference was funded
by the Research Council of Norway's FRIPRO scheme for independent
projects.
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mechanistic hypotheses and patient stories in risk assessment of drugs.
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ORCID
Samantha Copeland
http://orcid.org/0000-0002-6946-7165
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How to cite this article: Anjum RL, Copeland S, Kerry R,
Rocca E. The guidelines challenge—Philosophy, practice, policy.
J Eval Clin Pract. 2018;1–7. https://doi.org/10.1111/jep.13004