Epistemic lenses and virtues, beyond evidence-based medicine
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Dr Mark Murphy's keynote presentation from the Health Libraries Group Conference 2018 on encouraging clinicians to source evidence-based material and share decisions with patients
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Epistemic lenses and virtues, beyond evidence-based medicine
- 1. Epistemic lenses and virtues, beyond evidence-based medicine Mark Murphy General Practitioner Lecturer, Department of General Practice, RCSI HRB SPHeRE PhD Scholar @drmarkmurphy markmurphy@rcsi.ie
- 2. Declarations of Interest Non-financial COIs (none) Lecturer, Royal College of Surgeons, Ireland HRB Centre of Primary Care Research GP
- 3. Evidence based medicine Other perspectives/ lenses on EBM Virtues which may facilitate this process
- 6. Asymmetry Processes SUM Research
- 7. 1. The first drug I can give you will reduce your chance of having a heart attack by 50% Which drug would you take? 2. The second drug will reduce the risk of you having a heart attack by a total of 1% 3. There is a third drug: 100 persons would have to take this drug every day for four years so that one person will benefit and not get a heart attack (the rest take the drug with no benefit) Asymmetry Processes SUM Research Patients Doctors Understandin g Public
- 8. Treatment Prognosis Diagnosis A medication … which has a (small) absolute risk reduction …. of a specific outcome occurring …. derived from (hopefully a high quality) RCT … generalised to our patient …. which may a risk of the following side effects Therapeutic Option Benefits Side effects Asymmetry Processes SUM Research
- 9. Frank Moriarty et al. 2015 Treatment Prognosis Diagnosis Asymmetry Processes SUM Research
- 10. Treatment Prognosis Diagnosis Asymmetry Processes SUM Research
- 11. Treatment Prognosis Diagnosis Asymmetry Processes SUM Research Informed consent
- 12. Therapeutic Option 3 Benefits Side effects Therapeutic Option 2 Benefits Side effects Therapeutic Option 1 Benefits Side effects Therapeutic Option 4 Benefits Side effects Asymmetry Processes SUM Research
- 13. Asymmetry Processes SUM Research Bypassing traditional academic pathways QI Science- can we over-reach sometimes? Understanding of EBM and research methods: HSR, mixed methods research poorly recognised Too Much MedicineEffective care The Bigger Picture
- 14. 85% of expenditure on medical research is wasted John Ioannidis showed: - None of 1000s of research reports linking foods to conditions are correct - 1% of thousands of studies linking genes and disease are reporting linkages that are real Asymmetry Processes SUM Research Smith, BMJ, 2018
- 16. Language
- 17. Language Explaining imagined phenomena Metaphors Like a fingerprint Pumped up the immune system Personal trainer Trogen et al. JAMA 2017
- 18. Language Must be careful to avoid linguistic deceit Treatment Prognosis Diagnosis
- 19. Medical history Foundations Rise Supernatural Serendipitous
- 20. 0 10 20 30 40 50 60 70 80 1750 1800 1850 1900 1950 2000 Ireland Italy UK Sweden Life expectancy > 10 years of age Age Year Cortisone 1949 Penicillin 1941 Targeted immunotherapies 2002 Era 1 Protectionism Era 2 Reductionism Era 3 Moral John Snow 1854 Housing ? Food ? Self-regulating, paternal profession Variations of care External accountability and measurement Ackernecht. History of Medicine Our World in Data LeFanu. Rise and Fall Modern Medicine Berwick. Era 3 for Medicine and Healthcare Less mandatory measurement, complex incentives From business to quality
- 21. Libraries Bedside Laboratories Ackernecht. History of Medicine
- 23. Mysticism ANDTruth-telling Fulfillment of the therapeutic potential of the consultation
- 24. Mysticism HopeCompassion EmpowermentUncertainty Risk explanation Bio-medical Truth-telling Fulfillment of the therapeutic potential of the consultation The doctor as a drug (Balint) The scientific basis of our medical discipline can run counter to the mystical and supernatural perceptions of the patient
- 25. Mysticism Bertrand Russell ‘A scientific attitude of mind involves a sweeping away of all other desires in the interests of the desire to know’. Can humans suppress: ‘hopes and fears, loves and hates… the whole subjective life, without preconceptions, without bias’?
- 27. Epistemology & Philosophy Knowledge Justification Belief Truth A factive verb Knowledge implies getting at the truth, but truth is not simple. Post-complexity world Baggini 2017
- 28. Epistemology & Philosophy Rationalism Indubitable | Incorrigible | Infallible Empiricism Too high a bar (e.g. for General Practice)? But we have a responsibility as epistemic agents Medical truths rarely reach the same truths as geometric truths Baggini 2017
- 29. Epistemology & Philosophy We cannot believe others when they speak truths, for knowledge is threatened by epistemic authority. When we defer to experts, we accept the authority of our own judgement in order to decide whose authority to believe Scientific knowledge is empirical, discovered through our senses and perceptions, with all their fallibilities Much of Medicine relates to OBSERVED EXPERIECNE, underpinning the importance of experience- including ‘foreground and background’ context in HSR Rationalism Empiricism Baggini 2017
- 31. How we think & Logic Can logical reasoning generate wisdom (syllogisms & inferential logic)? Cognitive biasesLogic Reason often does not just need logic, but experience, subtlety of thought and judgement; we can exaggerate assumptions All men are mortal Socrates is a man Socrates is mortal Major premise Minor premise Conclusion
- 32. How we think & Logic Much of our cognitive processes are automatic, with quick emotional processes dominating rather than a calm analysis Humility We are not rational but rationalisers Cognitive biases Cognitive biasesLogic
- 33. How we think & Logic …. Exposure (numerical data) Prevalence Category 1 Category 2 Binary thinking Black and white thinking Discontinuous thought
- 35. Too Much Medicine Modern medicine, despite noted successes, has an increasing ability to harm both the sick and the healthy Many drivers of over-medicalisation (technology, commercial and professional vested interests, legal and policy incentives and cultural beliefs) Much of medicine lacks robust trial-evidence (Vinay Prasad) A culture of ‘more is better’ and ‘to do something is positive’ dominates Medicine. Ageing Medicine ‘has colluded in the wider societal project of seeking technical solutions to the existential problems posed by the finitude of life and the inevitability of ageing, loss, and death’ (Iona Heath)
- 36. Politics
- 37. Politics We need honesty about when our opinions are POLITICAL Scarce resources | Funding pressures Rationing Opportunity cost Market incentives | Supplier induced demand Complexity of health policy undermined by non- complex thinking (who makes policy and who are vested interests?)
- 38. Lenses Language History Mysticism Philophy Psychology/ Logic Too Much Medicine Uncertainty Politics Virtues Modesty (acknowledge uncertainty) Skepticism (not cynicism)Openness to other perspectives on ‘truth’ Speak truth to power Desire to make better truths (honesty) Spirit of collective inquiry Morality comes with better knowledge Think- for ourselves, but not by ourselves Acknowledge meta- physical and spiritual truths (in others)
- 39. ‘Sapere aude’
- 40. Evidence based medicine Other perspectives/ lenses on EBM Virtues which may facilitate this process
Editor's Notes
- Learn about librarian conference and audience - Read highlighted yellow text READ SAPIENS ON language; Bring the books (history, facts and knowledge) Something personal about librarians Keele, invite and the conference themeCONTEXT
- Something personal about librarians Keele, invite and the conference theme CONTEXT Evidence What is means to me, as a GP, as an educator, someone in researcher, who is struggling with a political system What this perspective means for you?
- What is the central tenant of Medicine if not evidence? Expected by patients, demanded by regulators, evidence separates the healthcare professional from the alternative therapist.
- Yet in our noble effort to define and defend our craft, we have, at times, falsely elevated our sense of evidence and assumed it synonymous with concepts like knowledge, truth, logic, and wisdom. As custodians of medical knowledge, healthcare librarians have a prominent role to play. Already, significant responsibilities fall on healthcare librarians to support undergraduate and postgraduate learning and education, facilitating knowledge dissemination and transfer. Competencies such as communications, systematic reviewing, critical appraisal, management, organisation of health information, training, legal skills, ICT innovation and understanding the components healthcare environment are widening for the healthcare librarian. At a time when alternative facts predominate, with a rush to simplistic falsehoods, we require broader lenses and an appreciation of epistemic virtues, which can act as a rudder in our continuous understanding of medical knowledge.
- Multivariate analysis models Prediction Population attributable risk Branford Hill Criteria for causation Diagnosis understanding- LRs, PPVs
- False Gods: ICT innovations in particular are rarely fully costed and in the increasingly consumerist nature of the healthcare environment, the advertising of these policies can lead to their enactment.
- READ SAPIENS ON THIS Homo heidelbergensis- first hominid to make controlled vocalisations. We use language to describe complex, imagined phenomena such as probabilities of future events. Semantics of medicine remains understudied
- READ SAPIENS ON THIS Homo heidelbergensis- first hominid to make controlled vocalisations. We use language to describe complex, imagined phenomena such as probabilities of future events. Semantics of medicine remains understudied
- We use language to describe complex, imagined phenomena such as probabilities of future events. Semantics of medicine remains understudied
- Semantics of medicine understudied
- PRACTICE WHAT I AM SAYING HERE Ackernecht’s treatise on the history of Medicine notably undermines an historical knowledge-based foundation to our trade (15). With the Enlightenment, Medicine became ‘scientific’ and the evidence we now hold dear, was owned by our discipline. Medicine moved from libraries, to the bedside, to the hospital and laboratory in the 19th Century (15). The rise of modern medicines brought undoubted benefits, including penicillin (1941), cortisone (1949), the hip replacement (1961) and since 2002, targeted immunological therapies (16). Le Fanu argues that medical innovation has ‘run of out of steam’. The serendipitous advances which led to Medicine’s rise have undoubtedly improved healthcare, but little has happened since- with evidence patchily translated and shared with patients (16). It is hoped that we can reject the protectionism of era 1 of medicine and the reductionism of era 2, and become a moral era for a new Medicine (17). But we need to quantify the extent to which medicine has been the driver of improved healthcare outcomes.
- As certain disease died away, it is only inevitable that humans must die of other diseases- for we after all, mortal It means that future disease should not be the focus of our current fears (20). A society which misappropriates risks dominates modernity, yet we dare not speak about the inevitability of life- our death (20, 21). Whose responsibility is it to reframe the misplaced interpretations of probability and risk in our population?
- Doctors must be truthful, but must also fulfil the powerful therapeutic component of the doctor-patient relationship, balancing the sharing of absolute risks of benefits and harms, with hope, empowerment and compassion. Placebo and the doctor-as-a-drug phenomenon underlies the complexity of the social science of our discipline (16, 23). The scientific basis of our medical discipline can run counter to the mystical, and supernatural perceptions of the patient. Explanation of drug side-effects and negative expectations deriving from the clinical encounter, can produce negative outcomes, known as nocebo effects (22).
- Doctors must be truthful, but must also fulfil the powerful therapeutic component of the doctor-patient relationship, balancing the sharing of absolute risks of benefits and harms, with hope, empowerment and compassion. Placebo and the doctor-as-a-drug phenomenon underlies the complexity of the social science of our discipline (16, 23). Nocebo, metaphysical and supernatural thoughts
- The consultation must incorporate the metaphysical and philosophical needs of the patient
- Knowledge is a broad, complex, linguistic, cognitive and philosophical construction. ‘To know’- a factive verb- implies that an embedded proposition is true. We almost assume that the processes of medicine are also factive. Knowledge implies getting at the truth, but truth is not simple. We are are not in a post truth world but in a post-complexity world’
- Descartes may have set the bar for knowledge too high when he said it should be indubitable, incorrigible or infallible- certainly for a social science like General Practice. We have a responsibility as epistemic agents, to be aware of our beliefs, to ensure they clear and distinct and they are they justified But the argument that knowledge requires strong justification and strong belief, as a necessary condition for knowledge, is useful. (25). We are not living up to our responsibilities if we are without appropriate interrogation of whether our beliefs really are true (25). But evidence- in the grey world of a Generalist- rarely reaches the heights of truth. There is security in the rationalist quest for genuine unchanging knowledge, which is not derived from our perceptions of the world. Although perhaps philosophically arguable, rationalism is overly purist for Medicine and absolute certainties are more appropriate for geometric and mathematical theory. What we hold to be true should be open to being tested.
- Positivism Whilst we MIGHT maintain this standard for us- DOES NOT MEAN patients maintain this stand which is one of the important asymmetries I mentioned at the start. Much of medicine relates to observed experience, which underpins the importance of experience for foreground and background knowledge. Equally, we cannot believe others when they speak truths, for knowledge is threatened by epistemic authority. Two of the most common validators of ‘fact’ include ‘expertise’ and ‘eminence’ which EBM has tried to replace. When we defer to experts, we accept the authority of our own judgement in order to decide whose authority to believe.
- With Hume’s arguments against rationalism, it has been assumed that logical reasoning can generate wisdom. We can make arguments overly logical however- overly simplifying them- stripping them of ambiguity, vagueness and the complexity. Rather than revealing logic, we can exaggerate assumptions, which is an illusion. Reason does not just need logic, but experience, subtlety of thought and judgement (25). Much of our cognitive processes are automatic, with quick emotional processes dominating rather than a calm analysis (26, 27). Acknowledging our many cognitive biases- including anchoring effects, black-and-white thinking and confirmation bias- are essential and need to taught at undergraduate and postgraduate level (28). They instil humility. But since it is argued that humans ‘are not rational, but rationalisers’, our ability to identify biases in our own cognitive functioning, remains uncertain (25).
- With Hume’s arguments against rationalism, it has been assumed that logical reasoning can generate wisdom. We can make arguments overly logical however- overly simplifying them- stripping them of ambiguity, vagueness and the complexity. Rather than revealing logic, we can exaggerate assumptions, which is an illusion. Reason does not just need logic, but experience, subtlety of thought and judgement (25). Much of our cognitive processes are automatic, with quick emotional processes dominating rather than a calm analysis (26, 27). Acknowledging our many cognitive biases- including anchoring effects, black-and-white thinking and confirmation bias- are essential and need to taught at undergraduate and postgraduate level (28). They instil humility. But since it is argued that humans ‘are not rational, but rationalisers’, our ability to identify biases in our own cognitive functioning, remains uncertain (25).
- rational decision making often gets irrational because persons make decisions based on their perceived necessary choices - not their actual available choices.
- Medicine’s ability to overmedicalise has been known for centuries, with unwarranted variations in medical care. John Alison Glover, in 1938, highlighted widespread variation in tonsillectomy rates in London, driven by professional opinion rather than clinical need (11-13). James McCormick- an Irish GP- and Petr Skrabanek in 1989 highlighted the follies of modern medicine and its potential to harm rather than cure (3). Wennberg pioneered the study of variation of medical practice in US and this has heralded research into the factors which cause variation, be they professionally-driven, preference-driven or supply-driven
- something is off focus….. And it is regaining that focus that I think I want Vinay Prasad has articulated the inertia and conservatism within the medical profession, refusing to accept that many of our modern interventions lack robust trial-evidence The example of the ORBITA trial, with regards to stenting for symptomatic coronary artery disease is one case in point. highlight and lead a discussion on today As mentioned previously, humans live in a permanent fear of risks which might come so ‘we must do something about it’
- 27 million consultaitons each year
- 27 million consultaitons each year
- We need a deeper understanding of what we mean by knowledge and evidence, including philosophical and psychological scrutiny Epistemic virtues, seen through these broader lenses, can facilitate this journey and remove our blind-spots, our biases and our automatic linguistic deceptions. We need to promote and nurture epistemic virtues such as
- In the context of threats to our discipline, commodification of healthcare, development of untested technological and biomedical innovations, bypassing of cost-effective criteria, we must as a profession, ‘dare to know’. This means acknowledging the presence of epistemic virtues, which can open our mind to the wider lenses supporting medical evidence. Emanuel Kant’s definition of the Enlightenment in the late 18th Century.
- Something personal about librarians Keele, invite and the conference theme CONTEXT Evidence What is means to me, as a GP, as an educoator, someone in researcher, who is struggling with a political system What this perspective means for you?
- Clinical side- there is the linguistic deceipt of the words, the over-representation of effect, the knowledge that there is variation and just too much bloody medicine. Research perspective, we need evidence to underpin BOTH our professions