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Best Practice

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Document Typology: Article
Target groups: Health Workers,Students
country Where It Took Place: Other
Name of compiler: Tania Re
name of institution: Cipes piemonte
role: Project coordinator
language Of The Description: English
title: The marriage of evidence and narrative: Scientific nurturance within clinical practice.
description Of The Best Practice:
Published elaborations of evidence-based medicine (EBM) have failed to materially integrate the domains of interpersonal sensibility and relationship with tools intended to facilitate attention to biomedical research and knowledge within clinical practice. Furthermore, the elaboration of EBM skills has been confined to a narrow range of clinical research. As a result, crucial tools required to connect much clinically relevant research and practice remain hidden, and explorations of the deeper challenges faced by practitioners in their struggle to integrate sound science and shared clinical action remain elusive.
Within the resulting model, a tool of representation, whose components are Problem delineation, Actions, Choices and Targets, enables the clinical problem to be delineated and the patient and practitioner perspectives to be concretely defined with reference to four classes of clinical interaction: ‘therapy’, ‘diagnosis’, ‘prognosis’ and ‘harm’. As a result, the ‘information literacy’ skills required to access, evaluate and apply clinical research using electronic resources are well defined but subordinated to shared appreciation of patient need. The model acknowledges the relevance of the full range and scope of scientifically derived medical knowledge. For doctors, what lies beyond doubt, passion, and task feels less like the madness of art and more like the maddening quest for answers. Taunted by death, chilled by the unknown, reproached by ambiguity, we doctors defy the dark, brandishing whatever truthiness we might have at our disposal. Humours, meridians, alchemy, or molecular biology, our scientific beliefs themselves are not as important as is the slim and ultimately betraying comfort they temporarily provide. With rare exceptions (William Osler's bedtime reading)
Quality indicators:
Use of means of narrative medicine
A concrete proposal to integrate NM and EBM
A model based on integration of NM and EBM can lead to instructional tools that integrate clinical epidemiological knowledge with enforced consideration of differing patient and practitioner perspectives. It also may inform avenues for qualitative research into the processes through which such differing perspectives can be productively identified and shared.
Medical practice is poised astride insoluble tensions between the known and the unknown (or at least the knowable and the unknowable), the universal and the particular, and the body and the self. Nested, these tensions beget and amplify one another. The unwary physician, caught in the headlights of one of them, usually succumbs to the paralysing effects of all three, often without knowing what waylaid him or her on the country road to begin with. The tensions have yet to be adequately captured in language. We try to depict the oppositions so that we can at least see what challenges us, but such simplifying formulations as art versus science or nice doctor versus good doctor or illness versus disease do not convey the fundamentality of the conflicting forces. The question is not simply whether medicine is instrumental or imaginative, or whether it requires compassion along with competence, or whether humanities should be required in the medical school curriculum. It has, rather, to do with the nature of health, the problem of pain, the sources of suffering, and the fact of death. These questions are as big as questions get, bristling with profound ontological and existential considerations of human worth, of singularity, of chance, and of form.

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