Evidence-based medicine, clinical uncertainty, and learning to doctor

For the past two decades, evidence-based medicine (EBM), or the reliance on current scientific evidence to reach medical decisions, has been embraced as a new paradigm to standardize clinical care. Drawing from in-depth interviews with seventeen pediatric residents in two residency programs, we evaluate the extent to which the medical sociology scholarship on uncertainty analytically elucidates the recent influx of EBM during residency training. Our findings suggest that residents interpret EBM in varying ways to match their work practices: "Librarians" consult the literature while "researchers" evaluate it critically. For both groups, EBM might generate new uncertainties due to the increased reliance on information technologies and epidemiology. Whether EBM reduces uncertainty depends upon the residents' understanding of standardized knowledge and consequent incorporation of EBM in their clinical practice. Contrary to the predictions of some sociologists, EBM does not lead to a diminishment of humanitarian values in medical care. Nor does EBM lead to a science-based meritocracy on the patient ward, as claimed by some EBM advocates. Our conceptual updating of uncertainty emphasizes the continuous management of uncertainty during the medical socialization process. We argue that managing uncertainty develops along with what we term evidence-based clinical judgment.     

Evidence‐Based Medicine or Cookbook Medicine? Addressing Concerns over the Standardization of Care

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.     

Decision‐Making in Paediatric Rehabilitation: Exploring Professionals' and Children's Views on Decision‐Making Involvement

The article explores the distinction that professionals make between difficult and less difficult decisions in paediatric rehabilitation interventions. This distinction is explored by looking at the involvement of two children in decisions regarding paediatric rehabilitation interventions. The article argues for a clinical practice where children's experiences are extensively used to improve practice and to accommodate the child's right to participate in medical decisions concerning their own body and life. The different ways the children and the professional describe their experiences provide an avenue for a discussion on how medical reasoning can curtail children's involvement in decisions.     

Medical students' and tutors' experiences of directed and self-directed learning programs in evidence-based medicine: a qualitative evaluation accompanying a randomized controlled trial

This qualitative study aims to interpret the results of a randomized controlled trial comparing two educational programs (directed learning and self-directed learning) in evidence-based medicine (EBM) for medical students at the University of Oslo from 2002 to 2003. There is currently very little comparative educational research in this field. In the trial, no statistically significant differences between the study groups were shown for any outcomes considered (EBM knowledge, skills, and attitudes). Further analysis suggests that main reason for the negative trial results was that the majority of students learned equally effectively, whichever program they received, although implementation of the educational programs was not complete because of varying attendance. This study illustrates a stepwise evaluation model that might be useful in evaluating other socially complex interventions.     

Research evidence utilization in policy development by child welfare administrators

An exploratory qualitative study was conducted to explore how child welfare administrators use research evidence in decision-making. Content analysis revealed that a cultural shift toward evidence-based practice (EBP) is occurring in Canadian child welfare organizations and multiple types of evidence inform policy decisions. Barriers to using evidence include individual, organizational, and environmental factors. Facilitating factors include the development of internal champions and organizational cultures that value EBP. Integrating research into practice and policy decisions requires a multifaceted approach of creating organizational cultures that support research utilization and supporting senior bureaucrats to use research evidence in policy development.     

Are curriculum decisions based on the evidence? How social work faculty members make choices in curriculum decisions

An important step in translating evidence-based practice and empirically supported interventions into large-scale service improvements is to develop an understanding of practitioners' education and training in these practices. This understanding begins with discovering the factors that influence the decision-making process by social work faculty regarding curriculum content for master's level social work programs. This exploratory study uses quantitative and qualitative survey data to examine the decision-making process used by 42 master's level social work programs to select the models of direct practice taught in their master's level social work programs, and whether evidence-based practice and research evidence influences those decisions. We investigate faculty perceptions of curriculum effectiveness and discuss implications of our findings for social work educators making content and organization decisions regarding master's level social work curriculum.     

Evaluating the use of assessment paradigms for preventive interventions: A review of the Triple P — Positive Parenting Program

Public interest and research literature on preventive interventions have grown exponentially in the last three decades (O'Connell, Boat, & Warner, 2009), and the accountability of preventive interventions has come to the forefront of research as stakeholders and consumers increasingly require evidence to support prevention practices (Biglan, Mrazek, Carnine, & Flay, 2003; Flay et al., 2005; Wandersman & Florin, 2003; Weissberg, Kumpfer, & Seligman, 2003). A major goal for preventive interventions is to provide evidence that observed individual and community-level outcomes are a result of the intervention (Glass et al., 2013; Gottfredson et al., 2015). However, preventive interventions require the use of unique assessment methodology to establish evidence supporting the intervention. The present paper seeks to: 1) identify measurement issues within preventive models, 2) examine the interface of theory and practice in evaluating outcomes, and 3) review the implementation of an assessment paradigm in establishing support for a leading preventive intervention.The scope of the paper is limited to preventive interventions for children at risk for psychosocial problems and child maltreatment. A selected parent training model, the Triple P — Positive Parenting Program (Triple P; Sanders, 1999) is highlighted because it has emerged as a leader in the use of a rigorous, multi-level, prevention-focused assessment methodology. This paper adds to the extant literature by providing a theoretical review of assessment within preventive interventions and reviewing the Triple P approach to implementing this methodology successfully. Future directions are discussed.     

Social workers' assessments of needs and interventions for adolescents with substance misuse problems,criminal behaviour and mental health difficulties: a vignette study

The aim of the current vignette study was to examine how social workers assess adolescents with substance misuse problems, criminal behaviour and mental health difficulties, and how they make decisions about treatment interventions to reduce these problems. Earlier research has shown lack of knowledge concerning factors and processes that govern assessments and decisions in social work practice. In this anonymously administered survey, social workers in Stockholm, Sweden, were invited to assess fictitious youth issues. We found that social workers recognise the problems and needs of young people, but that they find it harder to link needs to evidence-based interventions. Also, there is a tendency to overrate alleged non-serious problems in the vignettes. We conclude that there is a need for increased knowledge about evidence-based methods and more structured procedures to broaden the basis for decisions.     

Case Work in Social Work: Exploring the use of Reflective Letters in the Intensive Family Support Services

This paper begins by reviewing the current policy context of ‘evidence based interventions’, a term littered in social work literature and more recently working with complex families in Wales. This study demonstrates the application of practice of a range of workers located in the Integrated Family Support Services (IFSS) in Wales in the context of reflective letters utilising motivational interviewing (MI) techniques. As part of the MI method, which is used as a model for practice in the IFSS, the consultant social worker, alongside other practitioners, uses a range of tools including the use of reflective letters and narrative principles. These letters are evidence themselves of the work and therapeutic conversations that happen during sessions within the family home, and with various family members. This paper draws on 14 samples of reflective letters from current practice in Wales and explores and considers their application to practice and areas for further development.     

How Effective are Interventions to Enhance Adherence to Psychiatric Medications? Practice Implications for Social Workers Working With Adults Diagnosed With Severe Mental Illness

This study integrates eight systematic reviews of adherence enhancement interventions to develop practice guidelines for social workers who work with adults who do not adhere to prescribed psychiatric medications. Findings indicate that existing investigations are disparate in their adherence definitions, methodologies employed, and sampling strategies, rendering it difficult to construct overall guidelines for social work practice. However, themes associated consistently with increased adherence are collaboration between clients and providers regarding medication decisions, consistent follow-up care, and a comprehensive network of professionals and caregivers who support clients in their use of medication to facilitate stabilization of mental health symptoms.     

Engagement in Mental Health Treatment Among Adolescents and Young Adults: A Systematic Review

The purpose of the present study is to review empirical evidence of the effects of interventions designed to improve engagement in mental health services among adolescents, young adults and their families. Investigators searched relevant databases, prior reviews, and conducted hand searches for intervention studies that met the following criteria: (1) examined engagement in mental health services; (2) included a comparison condition; and (3) focused on adolescents and/or young adults. Effect sizes for all reported outcomes were calculated. Thirteen studies met inclusion criteria. Conceptualizations of engagement and measurement approaches varied throughout studies. Approaches to improving engagement varied in effectiveness based on level of intervention. Individual level approaches improved attendance during the initial stage of treatment. While family level engagement interventions increased initial attendance rates, the impact did not extend to the ongoing use of services, whereas service delivery level interventions were more effective at improving ongoing engagement. The review illuminated that engagement interventions framed in an ecological model may be most effective at facilitating engagement. Implications for future research and practice are discussed.     

Is there no “I” in “Team”? Interindividual-intergroup discontinuity effect in a Cournot competition experiment

Even though firms consist of teams of individuals, industrial organization experiments are typically conducted under the unitary player assumption with individuals representing firms. Against this practice, there is evidence that individuals’ decisions differ from those made by teams, and also from individuals’ decisions which affect both oneself and others. This study examines the empirical scope of the unitary player assumption (alternatively the “interindividual-intergroup discontinuity effect”) in the context of a Cournot competition experiment. In the first, standard, experiment (216 participants), we find no evidence for the discontinuity effect. Output choices of both individuals and teams are around the Cournot outcome. In a second experiment (198 participants), we use a recommendation to shift participants’ initial disposition towards the (off-equilibrium) collusive output. This triggers the discontinuity effect; individuals choose lower outputs and collude more than teams. This effect is persistent in the second half of the experiment, and is not caused by team-member discussion or by seating team members together. We discuss the interpretations and implications of our results.     

Dimensions for argument and variability in child protection decision-making

ABSTRACT

The purpose of this article is to analyse the arguments presented by 181 professionals in the child protection system of the Basque Country (Spain) to justify their decisions regarding the implementation of measures related to family preservation or separation. The implementation of a case vignette demonstrated variability in professional decision-making, with 62% of professionals choosing family preservation and 38% opting for family separation. A series of argument categories which can be used by most professionals when making decisions are extracted from analysis of the content. However, in spite of using similar types of arguments, the professionals differed in the importance they attributed to such criteria and their interpretations. Differences in decision thresholds were directly related to professionals’ beliefs regarding the benefits of the interventions analysed. To reduce this variability, reflecting on these beliefs and analysing the effectiveness of interventions in child protection to incorporate evidence of professional judgement are recommended. The present study, on the one hand, identifies the argument categories used to justify decisions and, on the other, analyses the existing variability when interpreting these categories.     

Assessment of workplace product accessibility: a human factors perspective

This paper illustrates the advantages of using human factors evaluation techniques as a method of informing rehabilitation service provider decisions about client care and assistive technology selection. Successful integration of accessibility evaluation techniques can strengthen an evidence based service program and offer service providers another tool for providing efficient, effective, and rapid services to individuals in need. With accessibility evaluation data showing the functional abilities required to operate a given product or set of products, it is possible to empirically demonstrate that an individual has the potential to successfully utilize the provided workplace equipment. Conversely, if the accessibility evaluation data reveal that the functional capabilities required to use a product exceed the capabilities of a given user, it would be possible to demonstrate the need for particular interventions or accommodations. With accessibility evaluation data, service providers can make better informed decisions about client care.     

A single-subject design of ergonomic intervention effectiveness for university employees in a new facility

As clinicians are searching for evidence to support their practice interventions, it is sometimes hard to find the "real-world" studies that incorporate the complexities of actual practice. Following calls in the public health, nursing and medical literature for clinicians to participate in practice-based evidence, this pilot study explores the effectiveness of a single-subject design for practice-based evidence. Twenty-five "well" university employees participated in an ergonomic intervention over the course of one academic semester that consisted of a 15 min ergonomic intake session, a 45 min group hands-on ergonomic educational session and a 15 min individual ergonomic consult in their offices. Participants were sent postural comfort surveys weekly and their subjective ratings were analyzed to determine the effectiveness of the intervention to decrease their perceived postural discomfort at a computer work station. Twenty-one of the twenty-five participants reported an improvement in postural comfort over the course of the study. This pilot study suggests that further investigation needs to be conducted to determine the effectiveness of hands-on ergonomic education and consultation for well populations working at computer workstations.     

Use of research evidence and implementation of evidence-based practices in youth-serving systems

Although the effectiveness of interventions for prevention and treatment of mental health and behavioral problems in abused and neglected youth is demonstrated through the accumulation of evidence through rigorous and systematic research, it is uncertain whether use of research evidence (URE) by child-serving systems leaders increases the likelihood of evidence- based practice (EBP) implementation and sustainment. Information on URE was collected from 151 directors and senior administrators of child welfare, mental health and juvenile justice systems in 40 California and 11 Ohio counties participating in an RCT of the use of community development teams (CDTs) to scale up implementation of Treatment Foster Care Oregon over a 3 year period (2010 − 12). Separate multivariate models were used to assess independent effects of evidence acquisition (input), evaluation (process), application (output), and URE in general (SIEU Total) on two measures of EBP implementation, highest stage reached and proportion of activities completed at pre-implementation, implementation and sustainment phases. Stage of implementation and proportion of activities completed in the implementation and sustainment phases were independently associated with acquisition of evidence and URE in general. Participation in CDTs was significantly associated with URE in general and acquisition of research evidence in particular. Implementation of EBPs for treatment of abused and neglected youth does appear to be associated with use of research evidence, especially during the later phases.     

Using psychodynamic interventions to engage in trauma-informed practice

In recent years, trauma-informed practice has received increased attention in the social work literature. Although the adoption of trauma-informed practice is necessary for preparing social workers to practice effectively with clients, these frameworks do not necessarily provide social workers with the specific skills for doing so. Therefore, we argue that using interventions grounded in contemporary psychodynamic theory can help transform them into trauma-informed practitioners. Psychodynamic psychotherapy interventions, especially from object relations and self psychology, align with many of the principles of trauma-informed practice (e.g. establishing an atmosphere of safety and acceptance, relying upon relational collaboration). We begin by discussing trauma-informed practice and then discuss how the use of psychodynamic psychotherapy interventions (holding environment, containment, and selfobject transferences) can facilitate the application of trauma-informed principles. We conclude with a case illustration of how to incorporate psychodynamic interventions into trauma-informed practice.