Journal of evaluation in clinical practice
-
It is now-at least loosely-acknowledged that most health and clinical outcomes are influenced by different interacting causes. Surprisingly, medical research studies are nearly universally designed to study-usually in a binary way-the effect of a single cause. Recent experiences during the coronavirus disease 2019 pandemic brought to the forefront that most of our challenges in medicine and healthcare deal with systemic, that is, interdependent and interconnected problems. ⋯ Researchers urgently need to re-evaluate their science models and embrace research designs that allow an exploration of the clinically obvious multiple 'causes and effects' on health and disease. Clinical examples highlight the application of various systemic research methodologies and demonstrate how 'causes and effects' explain the heterogeneity of clinical outcomes. This shift in scientific thinking will allow us to find the necessary personalized or precise clinical interventions that address the underlying reasons for the variability of clinical outcomes and will contribute to greater health equity.
-
Medical schools' curricula have expanded over the decades to incorporate important new medical breakthroughs and discoveries. Their current focus and overall structures remain, however, stubbornly captive of early 20th-century thinking, with changes having been undertaken in a piecemeal fashion. Indeed, since the notable Flexner reform in 1910, medical schools' study plans have suffered successive and typically always partial adjustments which have failed to keep up with scientific, technological and sociological change. ⋯ We have more evidence than ever about how to provide high quality, person-centered care, and to keep patients safe. Shame on us if there is any hesitation about applying this knowledge to make the healthcare experience better for patients and providers. Embracing change and making continuous improvements are essential and urgent priorities for medicine and healthcare and, as we describe in the current article, will become more and more indispensably important in our rapidly changing world.
-
Substance use-targeted harm reduction (HR) has successfully expanded from public health into clinical settings. Hospital-based providers are in positions to encounter, precipitate and/or mediate ethically fraught situations that can arise around clinical HR-informed interventions. We examine why these situations occur and how they might be better addressed. ⋯ HR's use in the general hospital and other clinical settings is a positive development, but one that brings with it new ethical demands. Broader knowledge of the principles of HR, of the application of those principles to the hospital setting, and of common-ground concepts from outside of HR could help facilitate productive ethical engagement around substance-using patients.
-
To realize the potential of precision medicine, predictive models should be integrated within the framework of decision analysis, such as the decision curve analysis (DCA). To date, its application has required individual patient data (IPD) that are often unavailable. Performing DCA using aggregate data without requiring IPD may advance the goals of precision medicine. ⋯ DCA informed by adequately powered and well-calibrated models using only summary statistical estimates (mean and SD) approximates well models using IPD. Use of aggregate data will facilitate broader integration of predictive with decision modeling toward the goals of individualized decision-making.
-
Myalgic encephalomyelitis (ME), also called chronic fatigue syndrome (CFS), is characterised by persistent fatigue, postexertional malaise, and cognitive dysfunction. It is a complex, long-term, and debilitating illness without widely effective treatments. This study describes the treatment choices and experiences of ME/CFS patients who have experienced variable levels of recovery. ⋯ Patients with ME/CFS describe independently constructing and managing treatment plans, due to a lack of health system support. Stigmatised and dismissive responses from clinicians precipitated disengagement from the medical system and prompted use of other forms of treatment.