The problem of evidence-based medicine: Directions for social science

Department of Community Health and Epidemiology, Centre for Clinical Research, Dalhousie University, 4th Floor-5790 University Ave. Halifax, NS, Canada B3H 1V7.
Social Science & Medicine (Impact Factor: 2.56). 10/2004; 59(5):1059-69. DOI: 10.1016/j.socscimed.2003.12.002
Source: PubMed

ABSTRACT Evidence-based medicine (EBM) is arguably the most important contemporary initiative committed to reshaping biomedical reason and practice. The move to establish scientific research as a fundamental ground of medical decision making has met with an enthusiastic reception within academic medicine, but has also generated considerable controversy. EBM and the broader forms of evidence-based decision making it has occasioned raise provocative questions about the relation of scientific knowledge to social action across a variety of domains. Social science inquiry about EBM has not yet reached the scale one might expect, given the breadth and significance of the phenomenon. This paper contributes reflections, critique and analysis aimed at helping to build a more robust social science investigation of EBM. The paper begins with a "diagnostics" of the existing social science literature on EBM, emphasizing the possibilities and limitations of its two central organizing analytic perspectives: political economy and humanism. We further explore emerging trends in the literature including a turn to original empirical investigation and the embrace of "newer" theoretical resources such as postmodern critique. We argue for the need to move the social inquiry of EBM beyond concerns about rationalization and the potential erasure of the patient and, to this end, suggest new avenues of exploration. The latter include analysis of clinical epidemiology and clinical reason as the discursive preconditions of EBM, the role of the patient as a site for the production of evidence, and the textually mediated character of EBM.

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Available from: Eric Mykhalovskiy, Aug 05, 2015
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    • "Evidence-Based Practice Paradigm Rooted in Bevidence-based medicine^, the term was officially coined in Canada over 25 years ago (Evidence-based Medicine Working Group 1992). Since then it has been upheld by international organizations such as the Cochrane Collaboration and has branched out across the professional disciplines (Mykhalovskiy and Weir 2004, p. 1060). EBP refers to the conscientious, explicit, and thoughtful use of the best available evidence in decision-making in order to deliver services that are safe and the most effective (Sackett et al. 2000). "
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    ABSTRACT: Abstract The primary objective of this paper was to balance the conversation about evidence-based practices in the treatment of traumatized children by making it more arts inclusive. We overview some of the theoretical and empirical knowledge about how the arts have unique capacities to address the complex needs of traumatized children. Our goal was to outline how the arts may uniquely address the sequelae of childhood trauma and to encourage their use as both an enhancement to evidence based practices and, as stand alone interventions.We will describe how the arts uniquely address the complex sequelae of childhood trauma and emphasize their far-reaching accessibility to all children requiring care.
    Journal of Child & Adolescent Trauma 03/2015; 8(1):21-31. DOI:10.1007/s40653-015-0036-1
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    • "Such work tends to invoke binary oppositions between evidence and values, science and art, and standardization and personalization. In order to empirically investigate, rather than reproduce, such dichotomies, social scientists are starting to ask new questions; how does EBM create new (representations of) patients, and what kinds of choices do EBM tools support or ignore (Mykhalovskiy and Weir, 2004). For example, Brody and colleagues reject the notion that EBM is more or less patient-centered than other forms of medicine but suggest EBM shifts from one type of standardized patient to another: away from pathophysiology – where 'individual patients' are represented by their organs, lab results, or molecules – towards the study of populations – where a patient may be represented by his/her age, gender, body weight, or behavior (smoking, diet, exercise, and work). "
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    ABSTRACT: Evidence-based medicine (EBM), which advocates clinical decisions are based on evidence from medical research, has become an important ideal pursued in contemporary medicine. EBM relies on two key principles: the evidence hierarchy and clinical practice guidelines. Both principles have been fiercely criticized, and critics often invoke the term ‘Cookbook medicine’ to stress the dangers and limitations of EBM. This article reviews diverse critical literature on EBM by drawing on the newly proposed subfield of “Sociology of Standards.” It reframes the manifold critiques on EBM as concerns over the harm that standardization can bring about and demonstrates how empirical sociological studies have contributed to a better understanding of EBM's justificatory basis and regulatory impact. First, it discusses the ‘politics of Evidence’ inherent in EBM's epistemological basis, secondly, explores the actual ‘evidence-base’ of its tools in practice, and third, addresses sociological debates on EBM's regulatory impact. In the concluding section, I argue that a ‘Sociology of Standards’ opens up new research avenues by allowing scholars to challenge – or at least empirically investigate – a host of dichotomies. By doing so, the role of the patient in EBM can be reframed to allow for more productive empirical investigations.
    Sociology Compass 06/2014; 8(6):823–836. DOI:10.1111/soc4.12184
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    • "Importantly, this research has illuminated the ways in which global policy interests may override national evidenceinformed policy-making when there are divergences between the two (Behague et al. 2009). Driven largely by donors and global organizations, the notion of evidence-informed policymaking is gradually being transferred to developing countries (Mykhalovskiy and Weir 2004). However, as Behague et al. (2009) elegantly demonstrates, evidence-based policy-making has, thus far, had limited impact on context-specific programmatic policy development and implementation at the national level in developing countries. "
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    ABSTRACT: Contemporary public policy, supported by international arbitrators of blood policy such as the World Health Organization and the International Federation of the Red Cross, asserts that the safest blood is that donated by voluntary, non-remunerated donors from low-risk groups of the population. These policies promote anonymous donation and discourage kin-based or replacement donation. However, there is reason to question whether these policies, based largely on Western research and beliefs, are the most appropriate for ensuring an adequate safe blood supply in many other parts of the world. This research explored the various and complex meanings embedded in blood using empirical ethnographic data from Pakistan, with the intent of informing development of a national blood policy in that country. Using a focused ethnographic approach, data were collected in 26 in-depth interviews, 6 focus group discussions, 12 key informant interviews and 25 hours of observations in blood banks and maternity and surgical wards. The key finding was that notions of caste-based purity of blood, together with the belief that donors and recipients are symbolically knitted in a kin relationship, place a preference on kin-blood. The anonymity inherent in current systems of blood extraction, storage and use as embedded in contemporary policy discourse and practice was problematic as it blurred distinctions that were important within this society. The article highlights the importance—to ensuring a safe blood supply—of basing blood procurement policies on local, context-specific belief systems rather than relying on uniform, one-size-fits-all global policies. Drawing on our empirical findings and the literature, it is argued that the practice of kin-donated blood remains a feasible alternative to the global ideal of voluntary, anonymous donations. There is a need to focus on developing context-sensitive strategies for promoting blood safety, and critically revisit the assumptions underlying contemporary global blood procurement policies.
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