What is the “received view” of EBM and how can we improve upon it? Dr. Tonelli and Dr. Bluym coauthored a text called “On What Evidence: Making the Case In Medical Decision-Making” seeks to give an alternative account on how to integrate medical evidence in clinical decision making aimed at medical educators.
They argue that there is a integration problem with the current view of evidence based medicine. Listen more to see how they articulate it and how they hope to resolve it through their model.
Let us know what you think of the episode in the comments!
Guest’s contact info:
https://depts.washington.edu/bhdept/mark-r-tonelli-md-ma
tonelli@uw.edu
Show Notes:
[0:00] Introduction
https://plato.stanford.edu/entries/medicine/
[4:00] What are the norms about rational discourse in the history of medicine? + The Integration Problem of EBM
Empiricism vs Rationalism & General knowledge vs Specific knowledge
The Integration Problem
“Overall, EBM’s major achievements have been to draw attention to the importance of clinical research for medical practice, to contribute to improvements in the quality and reporting of this research, and to promote the teaching of skills needed to critically appraise clinical studies. EBM, however, has been less successful in developing practicable methods for using this knowledge in clinical practice. For the most part, EBM simply asserts that, after identifying and assessing relevant clinical research sources, clinicians must integrate this evidence with their clinical experience, their knowledge of biology, and their patients’ values. It does not, however, explain how to do this: EBM has an integration problem."
Taken from Chapter 2 of the book “On What Evidence: Making The Case In Medical Decision-making”
[14:30] A brief introduction to the kinds of medical evidence available to the clinician (population level data, mechanistic reasoning, patient values, & clinical experience) + why we should not naively privilege population level studies in our clinical reasoning
Hierarchies of Evidence and where it falls short
Evidentiary Pluralism
Particularising from General Knowledge
RCTs make constrained causal claims that need other kinds of evidence to particularise to a patient context
“Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome” in the NEJM 2000 (https://www.nejm.org/doi/full/10.1056/NEJM200005043421801?utm_source=openevidence)
https://pubmed.ncbi.nlm.nih.gov/34217425/
[25:30] The upshot of case-based reasoning as a framework for medical justification is that it localizes the dispute clearly between clinicians
[29:00] The importance of social activities in making sense of medical justification & how different epistemic commitments inform how people look at the same evidence but come to different claims
https://global.oup.com/academic/product/making-medical-knowledge-9780198732617?cc=us&lang=en&
[37:00] Mechanistic reasoning is needed to evaluate population level research AND translate it from the research context to the local context
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60563-1/fulltext?wptouch_preview_theme=enabled
[43:00] The Case Based Reasoning approach for resolving the “Integration Problem”
Making your commitments explicit in clinical decision-making
Integrating values in the evidence discourse
