Perspectives in biology and medicine
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Perspect. Biol. Med. · Jan 2005
From autonomy to accountability: the role of clinical practice guidelines in professional power.
Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. Based on a systematic evaluation of the available scientific evidence, these guidelines offer recommendations for clinicians about details of patient care and clinical decision making. Because clinical practice guidelines specify how health care should be performed, they could be considered a threat to clinical and professional autonomy. ⋯ Professional organizations develop clinical practice guidelines as a service to their members but do not require strict adherence to the guidelines. Indeed, implementation studies show at best a modest change in clinical behavior. Such non-adherence might render a profession vulnerable, however, when third parties seize upon guidelines and offer financial incentives to keep clinicians accountable for delivering optimal patient care.
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Straw men play a major role in the debate over racial disparity in American medicine. Most have been deployed by the disparities-denying right, but progressives intent on "outing" racism have sent forth their share. This essay flushes out the straw men while attempting to understand the competing moral premises that drive the politics of health care disparity. ⋯ Further research into the factors that correlate with racial differences in health care can shed light on the circumstances that bring about these differences. Whether these circumstances, once understood, should be deemed acceptable is a moral and political matter, and sharp differences over the scope of personal and public responsibility for these circumstances are inevitable. Such disagreements, however, distract us from efforts to reach common ground solutions to agreed-upon inequities in health care.
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Narrative is ever present in medicine and is an integral aspect of the doctor and patient relationship. Although theoretical discussions of narrative medicine and narrative ethics are important, they may serve to reify the patient's story, to make it a specific entity. In practice, the patient's story unfolds in the moment of communication depending on the individuals and the circumstances; the story is not an "object." Patients' narratives heard in clinical settings are often limited by physician behaviors, especially the tendency of physicians to control the interaction with the patient. ⋯ If the patient's narrative is not heard fully, the possibility of diagnostic and therapeutic error increases, the likelihood of personal connections resulting from a shared experience diminishes, empathic opportunities are missed, and patients may not feel understood or cared for. The practice of mindfulness--moment-to-moment, nonjudgmental awareness--opens a doorway into the patient's story as it unfolds. Such mindful practice develops the physician's focus of attention and offers the possibility for a meaningful and important narrative to arise between patient and physician.
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Despite the recent blossoming of rigorous research into placebo mechanisms and the long-standing use of placebos in clinical trials, there remains widespread and profound misunderstanding of the placebo response among both practicing physicians and clinical researchers. This review identifies and clarifies areas of current confusion about the placebo response (including whether it exists at all), describes its phenomenology, and outlines recent advances in our knowledge of its underlying psychological and neural mechanisms. ⋯ In addition, this subfield of placebo research offers a specific neural circuit hypothesis capable of being integrated with equally rigorous experimental work on the psychological (including social psychological) and clinical levels. In this sense, placebo analgesia research bears all the marks of a genuine multilevel interdisciplinary research paradigm in the making, one that could serve as a model for research into other kinds of placebo responses, as well as into other kinds of mind-body responses.
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The randomized controlled trial (RCT) is not a gold standard: it is a good experimental design in some circumstances, but that's all. Potential shortcomings in the design and implementation of RCTs are often mentioned in passing, yet most researchers consider that RCTs are always superior to all other types of evidence. ⋯ This has important consequences for research methodology, for quality of care in clinical medicine, and--especially--for research funding policy. Because every study design may have problems in particular applications, studies should be evaluated by appropriate criteria, and not primarily according to the simplistic RCT/non-RCT dichotomy promoted by some prominent advocates of the evidence-based medicine movement and by the research evaluation guidelines based on its principles.