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  • 1.
    Howick, Jeremy
    University of Oxford.
    Mebius, Alexander ()
    Philosophy and History, KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy. University of Oxford.
    Thomas R, Fanshawe ()
    University of Oxford.
    Lewith, George ()
    Monash University.
    Bishop, Felicity ()
    University of Southampton.
    Mistiaen, Patriek ()
    Belgian Health Care Knowledge Centre (KCE).
    Roberts, Nia W ()
    University of Oxford.
    Dieninytė, Eglė ()
    Vilnius University.
    Hu, Xiao-Yang ()
    University of Southampton.
    Aveyard, Paul ()
    University of Oxford.
    Onakpoya, Igho ()
    University of Oxford.
    Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis2018In: Journal of the Royal Society of Medicine, ISSN 0141-0768, E-ISSN 1758-1095, Vol. 111, no 7, p. 240-252Article in journal (Refereed)
    Abstract [en]

    Background

    Practitioners who enhance how they express empathy and create positive expectations of benefit could improve patient outcomes. However, the evidence in this area has not been recently synthesised.

    Objective

    To estimate the effects of empathy and expectations interventions for any clinical condition.

    Design

    Systematic review and meta-analysis of randomised trials.

    Data source

    Six databases from inception to August 2017.

    Study selection

    Randomised trials of empathy or expectations interventions in any clinical setting with patients aged 12 years or older.

    Review methods

    Two reviewers independently screened citations, extracted data, assessed risk of bias and graded quality of evidence using GRADE. Random effects model was used for meta-analysis.

    Results

    We identified 28 eligible (n = 6017). In seven trials, empathic consultations improved pain, anxiety and satisfaction by a small amount (standardised mean difference −0.18 [95% confidence interval −0.32 to −0.03]). Twenty-two trials tested the effects of positive expectations. Eighteen of these (n = 2014) reported psychological outcomes (mostly pain) and showed a modest benefit (standardised mean difference −0.43 [95% confidence interval −0.65 to −0.21]); 11 (n = 1790) reported physical outcomes (including bronchial function/ length of hospital stay) and showed a small benefit (standardised mean difference −0.18 [95% confidence interval −0.32 to −0.05]). Within 11 trials (n = 2706) assessing harms, there was no evidence of adverse effects (odds ratio 1.04; 95% confidence interval 0.67 to 1.63). The risk of bias was low. The main limitations were difficulties in blinding and high heterogeneity for some comparisons.

    Conclusion

    Greater practitioner empathy or communication of positive messages can have small patient benefits for a range of clinical conditions, especially pain.

    Protocol registration

    Cochrane Database of Systematic Reviews (protocol) DOI: 10.1002/14651858.CD011934.pub2.

  • 2.
    Howick, Jeremy
    et al.
    University of Oxford.
    Ashley, Graham Kennedy
    Florida Atlantic University.
    Mebius, Alexander
    Philosophy and History, KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Philosophy of Evidence-Based Medicine2015In: Oxford Bibliographies in Philosophy / [ed] Duncan Pritchard, Oxford University Press, 2015Chapter in book (Refereed)
    Abstract [en]

    Since its introduction just over two decades ago, evidence-based medicine (EBM) has come to dominate medical practice, teaching, and policy. There are a growing number of textbooks, journals, and websites dedicated to EBM research, teaching, and evidence dissemination. EBM was most recently defined as a method that integrates best research evidence with clinical expertise and patient values and circumstances in the treatment of patients. There have been debates throughout the early 21st century about what counts as good research evidence between EBM proponents and philosophical critics and even within the EBM community itself. Similar controversy arises about the relative worth of patient values and clinical expertise (and how these can be integrated). EBM has also evolved in ways that have come under scrutiny. Specifically, policymakers have used EBM research methodology to increase the relative importance of clinical guidelines that some clinicians have argued are tyrannical. Philosophers have addressed all of these controversies, and with very few exceptions have been critical of EBM. In addition most philosophical attention has been on the epistemic role of Randomization and evidence hierarchies, with relatively little attention being paid to the role of Diagnosis, expertise, patient values, and Systematic Reviews within EBM.

  • 3.
    Howick, Jeremy
    et al.
    University of Oxford.
    Fanshawe, Thomas R
    University of Oxford.
    Mebius, Alexander
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy. Ludwig Maximilian University Munich.
    Heneghan, Carl J
    University of Oxford.
    Bishop, Felicity
    University of Southampton.
    Little, Paul
    University of Southampton.
    Mistiaen, Patriek
    Belgian Health Care Knowledge Centre (KCE).
    Roberts, Nia W
    University of Oxford.
    Effects of changing practitioner empathy and patient expectations in healthcare consultations2015In: Cochrane Database of Systematic Reviews, ISSN 1469-493X, E-ISSN 1469-493XArticle in journal (Refereed)
  • 4. Howick, Jeremy
    et al.
    Mebius, Alexander
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    In search of justification for the unpredictability paradox2014In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 15, no 480Article in journal (Refereed)
    Abstract [en]

    A 2011 Cochrane Review found that adequately randomized trials sometimes revealed larger, sometimes smaller, and often similar effect sizes to inadequately randomized trials. However, they found no average statistically significant difference in effect sizes between the two study types. Yet instead of concluding that adequate randomization had no effect the review authors postulated the "unpredictability paradox", which states that randomized and non-randomized studies differ, but in an unpredictable direction. However, stipulating the unpredictability paradox is problematic for several reasons: 1) it makes the authors' conclusion that adequate randomization makes a difference unfalsifiable-if it turned out that adequately randomized trials had significantly different average results from inadequately randomized trials the authors could have pooled the results and concluded that adequate randomization protected against bias; 2) it leaves other authors of reviews with similar results confused about whether or not to pool results (and hence which conclusions to draw); 3) it discourages researchers from investigating the conditions under which adequate randomization over- or under-exaggerates apparent treatment benefits; and 4) it could obscure the relative importance of allocation concealment and blinding which may be more important than adequate randomization.

  • 5.
    Howick, Jeremy
    et al.
    University of Oxford.
    Mebius, Alexander
    Philosophy and History, KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy. University of Oxford, UK.
    Randomized trials and observational studies: the current philosophical controversy2016In: Handbook of the Philosophy of Medicine / [ed] Schramme, Thomas and Steven Edwards, Springer, 2016, p. 873-886Chapter in book (Refereed)
    Abstract [en]

    The supposed superiority of randomized over non-randomized studies is used to justify claims about therapeutic effectiveness of medical interventions and also inclusion criteria for many systematic reviews of therapeutic interventions. However, the view that randomized trials provide better evidence has been challenged by philosophers of science. In addition, empirical evidence for average differences between randomized trials and observational studies (which we would expect if one method were superior) has proven difficult to find. This chapter reviews the controversy surrounding the relative merits of randomized trials and observational studies. It is concluded that while (well-conducted) observational can often provide the same level of evidential support as randomized trials, merits of (well-conducted) randomized trials warrant claims about their superiority, especially where results from the two methods are contradictory.

  • 6.
    Howick, Jeremy
    et al.
    University of Oxford.
    Thomas R, Fanshawe
    University of Oxford.
    Mebius, Alexander
    University of Oxford, United Kingdom.
    Bishop, Felicity
    University of Southampton.
    van Osch, Mara
    NIVEL (Netherlands Institute for Health Services Research).
    van Dulmen, Sandra
    Radboud University Medical Center.
    Christelis, Nick
    Monash University.
    Kaptchuk, Ted
    Harvard Medical School.
    Lewith, George
    Monash University.
    Mistiaen, Patriek
    Belgian Health Care Knowledge Centre (KCE).
    Positive "framing" as a powerful medication for pain: A meta-analysis of randomized trials2016In: European Journal of Integrative Medicine, ISSN 1876-3820, E-ISSN 1876-3839, Vol. 8, p. 57-59Article in journal (Refereed)
    Abstract [en]

    Introduction: A growing body of evidence suggests that positive framing–inducing positive expectations about the outcome of treatments can reduce pain symptoms. However there is no pooled estimate of the effect size of positive framing for treating pain. Such an estimate is useful to understand the extent to which positive expectations can enhance usual care.

    Methods: We extracted data from a recent systematic review of interventions that modified all "context factors" (including but not limited to) inducing positive expectations) in adults suffering from pain. The systematic review concluded that positive expectations were effective, but did not pool the results so no effect size was provided. Two authors independently extracted data from the studies and conducted the analysis. Our primary outcome was patient self-reported pain.

    Results: 10 randomized trials were eligible for meta-analysis. In the trials with continuous outcomes the standardized effect size was −0.39 (95% confidence interval −0.68 to −0.10, p = 0.009, I2 = 79%), suggesting reduced pain on average in groups in which positive expectations were induced. The effect size was similar in magnitude but was not statistically significant when we excluded studies deemed to have a high risk of bias (standard effect size −0.31, 95% CI −0.65 to 0.02, p = 0.07, I2 = 77%).

    Conclusion: The effect of inducing positive expectations is comparable to the effects of some pharmacological drugs. However many of the studies had a high risk of bias, and heterogeneity was significant. Future research is warranted including investigating ways to implement this evidence into patient care in an ethical way.

  • 7.
    Mebius, Alexander
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    A weakened mechanism is still a mechanism: On the causal role of absences in mechanistic explanation2014In: Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences, ISSN 1369-8486, E-ISSN 1879-2499, Vol. 45, p. 43-48Article in journal (Refereed)
    Abstract [en]

    Much contemporary debate on the nature of mechanisms centers on the issue of modulating negative causes. One type of negative causability, which I refer to as “causation by absence,” appears difficult to incorporate into modern accounts of mechanistic explanation. This paper argues that a recent attempt to resolve this problem, proposed by Benjamin Barros, requires improvement as it overlooks the fact that not all absences qualify as sources of mechanism failure. I suggest that there are a number of additional types of effects caused by absences that need to be incorporated to account for the diversity of causal connections in the biological sciences. Furthermore, it is argued that recognizing natural variability in mechanisms, such as attenuation, leads to some interesting line-drawing issues for contemporary philosophy of mechanisms.

  • 8.
    Mebius, Alexander
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    An omitted hallmark of mechanism functionManuscript (preprint) (Other academic)
  • 9.
    Mebius, Alexander
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Ascribing functions to medical technologiesManuscript (preprint) (Other academic)
  • 10.
    Mebius, Alexander
    Philosophy and History, KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy. University of Oxford.
    Assigning Functions to Medical Technologies2016In: Philosophy & Technology, ISSN 2210-5433, E-ISSN 2210-5441, p. 1-18Article in journal (Refereed)
    Abstract [en]

    Modern health care relies extensively on the use of technologies forassessing and treating patients, so it is important to be certain that health care technologies (i.e., pharmaceuticals, devices, procedures, and organizational systems) perform their professed functions in an effective and safe manner. Philosophers of technology have developed methods to assign and evaluate the functions of technological products, the major elements of which are described in the ICE theory. This paper questions whether the standard of evidence advocated by the ICE theory is adequate for ascribing and assessing technologies employed in health care. The paper proposes that the general problem with the standard of evidence embodied in the ICE theory (i.e.,testimony and evidence of mechanisms) is too permissive for assessing medical technologies, in that it does not take into account the relative benefit and harm of medical technologies in ensuring safe functional performance in patients. The paper illustrates how evidence-based medicine (EBM) has demonstrated the value of clinical research methods, including observational studies, randomized and non-randomized clinical trials, and formal techniques, such as meta-analysis, to measure therapeutic effectiveness. I argue, therefore, that evidence from clinical research studies should take precedence over the testimonial evidence and other types of non-clinical evidence, inproviding justification for health technologies.

  • 11.
    Mebius, Alexander
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Corroborating evidence-based medicine2014In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 20, no 6, p. 915-920Article in journal (Refereed)
    Abstract [en]

    Proponents of evidence-based medicine (EBM) have argued convincingly for applying this scientific method to medicine. However, the current methodological framework of the EBM movement has recently been called into question, especially in epidemiology and the philosophy of science. The debate has focused on whether the methodology of randomized controlled trials provides the best evidence available. This paper attempts to shift the focus of the debate by arguing that clinical reasoning involves a patchwork of evidential approaches and that the emphasis on evidence hierarchies of methodology fails to lend credence to the common practice of corroboration in medicine. I argue that the strength of evidence lies in the evidence itself, and not the methodology used to obtain that evidence. Ultimately, when it comes to evaluating the effectiveness of medical interventions, it is the evidence obtained from the methodology rather than the methodology that should establish the strength of the evidence.

  • 12.
    Mebius, Alexander
    KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Philosophical controversies in the evaluation of medical treatments: With a focus on the evidential roles of randomization and mechanisms in Evidence-Based Medicine2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    This thesis examines philosophical controversies surrounding the evaluation of medical treatments, with a focus on the evidential roles of randomised trials and mechanisms in Evidence-Based Medicine. Current 'best practice' usually involves excluding non-randomised trial evidence from systematic reviews in cases where randomised trials are available for inclusion in the reviews. The first paper challenges this practice and evaluates whether adding of evidence from non-randomised trials might improve the quality and precision of some systematic reviews. The second paper compares the alleged methodological benefits of randomised trials over observational studies for investigating treatment benefits. It suggests that claims about the superiority of well-conducted randomised controlled trials over well-conducted observational studies are justified, especially when results from the two methods are contradictory. The third paper argues that postulating the unpredictability paradox in systematic reviews when no detectable empirical differences can be found requires further justification. The fourth paper examines the problem of absence causation in the context of explaining causal mechanisms and argues that a recent solution (Barros 2013) is incomplete and requires further justification. Solving the problem by describing absences as causes of 'mechanism failure' fails to take into account the effects of absences that lead to vacillating levels of mechanism functionality (i.e. differences in effectiveness or efficiency). The fifth paper criticises literature that has emphasised functioning versus 'broken' or 'non-functioning' mechanisms emphasising that many diseases result from increased or decreased mechanism function, rather than complete loss of function. Mechanistic explanations must account for differences in the effectiveness of performed functions, yet current philosophical mechanistic explanations do not achieve this. The last paper argues that the standard of evidence embodied in the ICE theory of technological function (i.e. testimonial evidence and evidence of mechanisms) is too permissive for evaluating whether the proposed functions of medical technologies have been adequately assessed and correctly ascribed. It argues that high-quality evidence from clinical studies is necessary to justify functional ascriptions to health care technologies.

  • 13.
    Mebius, Alexander
    et al.
    Philosophy and History, KTH, School of Architecture and the Built Environment (ABE), Philosophy and History of Technology, Philosophy.
    Graham Kennedy, Ashley
    Florida Atlantic University.
    Howick, Jeremy
    University of Oxford, UK.
    Research gaps in the philosophy of evidence-based medicine2016In: Philosophy Compass, ISSN 1747-9991, E-ISSN 1747-9991, p. 1-15Article in journal (Refereed)
    Abstract [en]

    Increasing philosophical attention is being directed to the rapidly growing discipline of evidence-based medicine (EBM). Philosophical discussions of EBM, however, remain narrowly focused on randomization, mechanisms, and the sociology of EBM. Other aspects of EBM have been all but ignored, including (a) the nature of clinical reasoning and the question of whether it can be standardized; (b) the application of EBM principles to the logic, value, and ethics of diagnosis and prognosis; (c) evidence synthesis (systematic reviews and meta-analyses); and (d) the nature and ethics of placebo controls. Philosophical analysis in each of these areas has the potential to enhance the discussion of EBM methodology and practice. 

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