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
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
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
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
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’?
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)
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)
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