Journal of evaluation in clinical practice
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Pay-for-performance schemes reward standardized professional behaviours associated with effective care. However, they neglect the significance of virtue and devalue and erode professional motivation based on virtue. ⋯ These indicators could be based on virtues identified from a framework of universal virtues and through logical inferences from features of practice. It is possible that pay-for-virtue could ultimately strengthen health professionals' intrinsic motivation for good practice, but this and the broader effects of pay-for-virtue would need careful investigation.
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Much of medical research involves large-scale randomized controlled trials designed to detect small differences in outcome between the study groups. This approach is believed to produce reliable evidence on which the management of patients is based. But can we be sure that the demonstration of a small, albeit statistically significant, difference is sufficient to infer the presence of a causal relationship between the drug and the outcome? A study is claimed to have internal validity when other explanations for the observed difference - namely, inequalities between the groups, bias in the assessment of the outcome and chance - have been excluded. ⋯ The philosophical basis of large-scale randomized controlled trials and epidemiological studies is unsound. When examined closely, many obstacles emerge that threaten the inference from a small, statistically significant difference to the presence of a causal relationship between the drug and the outcome. Given the influence of statistics-based research on the practice of medicine, it is of the utmost importance that the flaws in this methodology are brought to the fore.
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Evidence-based medicine (EBM) is frequently portrayed as a value-free approach to knowing what kinds of treatment 'really work.' Since practitioners should help patients to improve their health, and EBM tells us which interventions will work, then it follows that we must practice EBM, offering only those interventions supported by evidence. The primary goal of EBM, then, is an ethical one - to improve health. More recently, EBM's authors have also committed themselves to 'shared decision making' in which evidence plays a role in the clinical encounter, but where patients, motivated by their own values, should have final decision-making authority. ⋯ Where they conflict, the aim of the intervention will determine which goal practitioners should pursue. Having increased the ethical complexity of EBM, we are left with the question of whether EBM would still be judged a success if it did not lead to much in the way of improvements in health, but primarily strengthened informed consent. This paper will conclude by arguing that this more nuanced version of EBM's ethics accurately reflects the dynamics of real clinical practice but undermines the original, perceived need for EBM.