Journal of evaluation in clinical practice
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Rationale, aims and objectives Evidence-based medicine (EBM) claims to be based on 'evidence', rather than 'intuition'. However, EBM's fundamental distinction between quantitative 'evidence' and qualitative 'intuition' is not self-evident. The meaning of 'evidence' is unclear and no studies of quality exist to demonstrate the superiority of EBM in health care settings. ⋯ Results EBM's strict distinction between admissible evidence (based on RCTs) and other supposedly inadmissible evidence is not itself based on evidence, but rather, on intuition. In other words, according to EBM's own logic, there can be no 'evidentiary' basis for its distinction between admissible and inadmissible evidence. Ultimately, to uphold this fundamental distinction, EBM must seek recourse in (bio)political ideology and an epistemology akin to faith.
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Randomized trials are undoubtedly different from observational studies, but authors sometimes propose differences between these designs that do not exist. In this article we examine two claims about randomized trials: first, a recent claim that the causal structure of exposure measurement (information) bias in a randomized trial differs from the causal structure of that bias in an observational study. ⋯ Using causal diagrams (causal directed acyclic graphs), we show that both claims are false in the context of an intention-to-treat analysis. We also describe a previously unrecognized mechanism of information bias, and suggest that the term 'information bias' should replace the terms 'measurement bias' and 'observation bias'.
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Prescribing decisions are not always based on published clinical research; social and environmental influences can sometimes drive such decisions. However, little is known about this topic in prescribing in secondary care. The aim of this study was to explore such influences by asking doctors to discuss their uncomfortable prescribing decisions in secondary care. ⋯ Incorporating the research evidence into prescribing decisions was associated with much discomfort by secondary care doctors. Greater efforts should also be placed towards developing the model of EBM, so that it fits more explicitly with how medicine is currently practised. Perhaps more importantly, educators need to reinforce what EBM is and what it is not to all concerned in the delivery of health care.
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First, we examine whether clinical guidelines, designed to improve health care and reduce disparities in clinical practice, are achieving their intended consequences. Second, we contemplate potential unintended consequences of clinical guidelines. ⋯ Consistent with other research we find that clinical practice guidelines are not producing a principal intended result, and may even produce unintended consequences.
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Rationale Extensive research has been conducted on clinical reasoning to gain better understanding of this process. Clinical reasoning has been defined as the process of thinking critically about the diagnosis and patient management. However, most research has focused on the process of diagnostic reasoning. ⋯ Subsequently, these processes adapt the therapy script continuously. Conclusions A hypothetical model of therapeutic reasoning has been developed in order to improve medical education, training and refresher courses with regard to therapeutic decision making. Future research should empirically test the validity of this hypothetical model in different phases of the medical education continuum.