Primary Care Health Sciences at the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
Department of Health Sciences, University of Oslo, Oslo, Norway.
Soc Sci Med. 2021 Mar;272:113702. doi: 10.1016/j.socscimed.2021.113702. Epub 2021 Jan 15.
To explore, from a philosophy of knowledge perspective, the contribution of the guideline development process to reducing epistemic uncertainty in clinical decision-making - defined as the challenge of applying evidence to patients, dealing with conflicting information and determining the level of confidence in a medical conclusion.
Longitudinal ethnographic study of national guideline development panels. Fieldnotes were collected from 19 panel meetings in UK, Netherlands and Norway (120 h of observation) between September 2016 and February 2019. Draft guidelines, review protocols and background material were collated (200 documents). Data were analyzed thematically to gain familiarity and then theorized using concepts of knowledge development and use and clinical decision-making.
Guideline development panels in all three countries wrestled with epistemic tensions - notably between the desire to "purify" an assumed external truth (for example by limiting included evidence to high-quality randomized controlled trials) and a more pragmatic and pluralist approach that drew on a wider range of evidence including qualitative research, real-world data, clinical experience and patient testimony. Detailed analysis of the process by which particular guideline recommendations were constructed allowed us to draw out the implications of these tensions for guideline users in clinical practice.
Guideline development panels apply multiple - often conflicting - understandings of knowledge, inference and truth in an attempt to reduce epistemic uncertainty. Guidelines makers, clinicians, scientists and students should engage critically and reflexively with the philosophical assumptions that underpin guideline development and inductive inference to build capability to deal with clinical complexity.
从知识哲学的角度探讨指南制定过程对减少临床决策中认识不确定性的贡献——将证据应用于患者、处理相互矛盾的信息以及确定对医学结论的置信度的挑战。
对英国、荷兰和挪威的国家指南制定小组进行纵向民族志研究。2016 年 9 月至 2019 年 2 月期间，共收集了 19 次小组会议的现场记录（约 120 小时的观察），并整理了指南草案、审查方案和背景材料（约 200 份文件）。通过主题分析对数据进行了分析，以熟悉数据，然后使用知识发展和使用以及临床决策的概念进行理论化。
所有三个国家的指南制定小组都在努力应对认识上的紧张局势——特别是在追求“净化”假设的外部真相（例如，将纳入的证据限制在高质量的随机对照试验）和更务实和多元化的方法之间的紧张局势，这种方法利用了更广泛的证据，包括定性研究、真实世界的数据、临床经验和患者证言。对特定指南建议构建过程的详细分析使我们能够得出这些紧张局势对临床实践中指南使用者的影响。
指南制定小组在尝试减少认识不确定性时，应用了多种（通常相互冲突）对知识、推理和真理的理解。指南制定者、临床医生、科学家和学生应批判性和反思性地参与指导方针制定和归纳推理所依据的哲学假设，以建立应对临床复杂性的能力。
