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Archived Comments for: Six ‘biases’ against patients and carers in evidence-based medicine

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  1. Part of a wider movement towards compassion and the alleviation of suffering in healthcare

    Shawn Walker, City University London

    15 September 2015

    This article resonated with me, as a researcher, a healthcare user, and a practising labour ward midwife. The biases identified by Greenhalgh et al arise from a critique of EBM grounded in compassion, which seeks to alleviate suffering rather than regulate conformity. I perceive a shift occuring from systems of prediction and control to relationship and response, but this revolution will take a long time to come to fruition. Person-based health care, in my opinion, needs to understand patient values and the source of individuals' suffering before treatment can be effective. Otherwise, EBM is in danger of creating more suffering.

    In an average shift on a labour ward, these tensions are played out. While I may spend hours with a woman in labour, gradually learning more about what is meaningful to her, and feeling confident about how the tools at my/our disposal may facilitate the process she is experiencing (a qualitative paradigm) - after a 10 minute review, her wishes and my instincts may be completely overruled by the evidence-based treatment indicated by her superficial clinical situation (a quantitative/positivist paradigm). I have absolutely no doubt that my esteemed and talented colleagues intend to do well and avoid suffering, but in seeking to maintain the values of EBM and its narrow definition of normality, more than occasionally further suffering is created in the erosion of the dignity and personal integrity of those we seek to serve.

    However, I do not see how this will change unless EBM itself recognises that the influence of complex, personal, and changing values may in fact mean that some clients choose courses of action which appear to health professionals to be reckless, and will sometimes result in outcomes they and/or health professionals may in retrospect wish had been avoided. The compilation of results tables to judge institutions and individuals in a nameless, faceless way contributes to this. Evaluations need to ensure a qualitative element as well.

    A possible limitation of shared decision-making in relationship rather than a menu of choices, is that it will still always be possible for health professionals to assume that, deep down, what the client really wants is X. And it will be easy to make that assumption as long as the vast majority of EBM promotes X as the desired outcome. Which brings the problem full-circle to the first of the outlined biases, the legacy of lack of patient involvement in defining the research agenda.

    And of course if we want health professionals to provide compassionate, patient-centred care, the health professionals need to be practising in a compassionate and respectful work environment, in a system which acknowledges the time it takes to provide this type of care. Often, time is the service, the care itself.

    Competing interests

    None declared