Perceptions of Clinical Experience and Scientific Evidence in Medical Decision Making: A Survey of a Stratified Random Sample of Swedish Health Care Professionals.

BACKGROUND: Evidence-based medicine recognizes that clinical expertise gained through experience is essential to good medical practice. However, it is not known what beliefs clinicians hold about how personal clinical experience and scientific knowledge contribute to their clinical decision making and how those beliefs vary between professions, which themselves vary along relevant characteristics, such as their evidence base. DESIGN: We investigate how years in the profession influence health care professionals' beliefs about science and their clinical experience through surveys administered to random samples of Swedish physicians, nurses, occupational therapists, dentists, and dental hygienists. The sampling frame was each profession's most recent occupational registry. RESULTS: Participants (N = 1,627, 46% response rate) viewed science as more important for decision making, more certain, and more systematic than experience. Differences among the professions were greatest for systematicity, where physicians saw the largest gap between the 2 types of knowledge across all levels of professional experience. The effect of years in the profession varied; it had little effect on assessments of importance across all professions but otherwise tended to decrease the difference between assessments of science and experience. Physicians placed the greatest emphasis on science over clinical experience among the 5 professions surveyed. CONCLUSIONS: Health care professions appear to share some attitudes toward professional knowledge, despite the variation in the age of the professions and the scientific knowledge base available to practitioners. Training and policy making about clinical decision making might improve by accounting for the ways in which knowledge is understood across the professions. HIGHLIGHTS: Study participants, representing 5 health care professions-medicine, nursing, occupational therapy, dentistry, and dental hygiene-viewed science as more important for decision making, more certain, and more systematic than their personal clinical experience.Of all the professions represented in the study, physicians saw the greatest differences between the 2 types of knowledge.The effect of years of professional experience varied but tended to be small, attenuating the differences seen between science and clinical experience.

Certainty and systematicity of practice-derived evidence matter for its relative importance in professional decision-making: Survey results on the role of proven experience in Swedish medicine, nursing, OT, dentistry, and dental hygiene.

Background: High-quality healthcare decisions need to balance input from science and clinical practice. When two sources of evidence - such as scientific and practice-derived evidence - are compared, integrated, or need to stand-in for one another, they need to be comparable on similar dimensions. Since 1891, Swedish physicians have been operating under a legal requirement to base their healthcare decisions on science and "proven experience" (approximately clinical expertise), and today all healthcare personnel in Sweden fall under this legal requirement. Objectives: We investigated the dynamics between these two kinds of evidence with respect to importance, systematicity, and certainty by studying Swedish healthcare professionals. Design: Survey to professionals; document studies of political discourse. Method: In this study, a survey was sent to simple random samples of Swedish professionals in medicine, nursing, occupational therapy, dentistry, and dental hygiene, asking about the roles of science and proven experience in medical decision making. Outcome measures were how important, certain, and systematic science and proven experience are for successful medical decision making. Participants: The sampling frame was each profession's most recent occupational registry accessed by the Swedish federal statistical agency. 3500 surveys were distributed. 1626 surveys were returned. 26 participants were removed prior to analysis (exclusion criteria: more than one profession indicated, missing certificate, and mistake in stratum). The final sample consisted of 295 physicians, 300 nurses, 365 occupational therapists, 339 dentists, and 301 hygienists. 162 responses in questions used as variables in the analyses were either uninterpretable or empty; those were replaced with the modal response for a given participant's profession on a given question. Results: In the study, proven experience's perceived importance for clinical decision making is positively correlated with its certainty and systematicity, and an increased certainty and systematicity is positively correlated with a diminished difference in importance between science and proven experience for almost all professions surveyed in this study. Conclusions: Proven experience has an evidentiary role in clinical decision making, and this role depends in part on its certainty and systematicity. Notably, this makes the EBM-based perspective that practice-derived knowledge is primarily of implementation value less plausible.

The epistemic roles of clinical expertise: An empirical study of how Swedish healthcare professionals understand proven experience.

Clinical expertise has since 1891 a Swedish counterpart in proven experience. This study aims to increase our understanding of clinicians' views of their professional expertise, both as a source or body of knowledge and as a skill or quality. We examine how Swedish healthcare personnel view their expertise as captured by the (legally and culturally relevant) Swedish concept of "proven experience," through a survey administered to a simple random sample of Swedish physicians and nurses (2018, n = 560). This study is the first empirical attempt to analyse the notion of proven experience as it is understood by Swedish physicians and nurses. Using statistical techniques for data dimensionality reduction (confirmatory factor analysis and multidimensional scaling), the study provides evidence that the proven experience concept is multidimensional and that a model consisting of three dimensions-for brevity referred to as "test/evidence", "practice", and "being an experienced/competent person"-describes the survey responses well. In addition, our results cannot corroborate the widely held assumption in evidence-based medicine that an important component of clinical expertise consists of experience of patients' preferences.

"Science and proven experience": How should the epistemology of medicine inform the regulation of healthcare?

The Swedish medico-legal concept of "science and proven experience" is both legally important and ambiguous. The conceptual uncertainty associated with it can hamper effective assessment of medical evidence in legal proceedings and encourage medical professionals to distrust legal regulation. We examine normative criteria a functioning medico-legal notion should presumably meet, e.g. clarity, acceptability and consistency with existing laws. We also survey healthcare professionals to see how they understand science and proven experience and thus determine the extent to which their understanding meets the normative criteria. The survey suggests that medical professionals feel more certain about "science and proven experience" in the medical context than they do in a legal context. They still have substantial trust in the legal use of the notion, but they do not believe that legal professionals should be allowed to determine the meaning of "science and proven experience" in the legal context. With these results in mind, we argue that the best way to meet the normative criteria and resolve conceptual uncertainty is to specify sub-questions that clarify the notion. We recommend an analytical-deliberative approach that will close the gap between the medical and legal professions' perceptions of how law and medicine relate.

Are values related to culture, identity, community cohesion and sense of place the values most vulnerable to climate change?

Values related to culture, identity, community cohesion and sense of place have sometimes been downplayed in the climate change discourse. However, they have been suggested to be not only important to citizens but the values most vulnerable to climate change. Here we test four empirical consequences of the suggestion: (i) at least 50% of the locations citizens' consider to be the most important locations in their municipality are chosen because they represent these values, (ii) locations representing these values have a high probability of being damaged by climate change induced sea level rise, (iii) citizens for which these values are particularly strongly held less strongly believe in the local effects of climate change, and (iv) citizens for which these values are particularly strongly held less strongly believe that they have experienced the effects of climate change. The tests were made using survey data collected in 2014 from 326 citizens owning property in Höganäs municipality, Sweden, and included values elicited using a new methodology separating instrumental values from end values, and using the former (which strictly speaking should be seen as estimates of usefulness rather than as aims in themselves) as stepping stones to pinpoint the latter, that represent the true interests of the respondents. The results provide the first evidence that, albeit frequent, values related to culture, identity, community cohesion and sense of place are not the values most vulnerable to climate change. This in turn indicates a need to further investigate the vulnerability of these values to climate change, using a methodology that clearly distinguishes between instrumental and end values.

Forest Owners' Response to Climate Change: University Education Trumps Value Profile.

Do forest owners' levels of education or value profiles explain their responses to climate change? The cultural cognition thesis (CCT) has cast serious doubt on the familiar and often criticized "knowledge deficit" model, which says that laypeople are less concerned about climate change because they lack scientific knowledge. Advocates of CCT maintain that citizens with the highest degrees of scientific literacy and numeracy are not the most concerned about climate change. Rather, this is the group in which cultural polarization is greatest, and thus individuals with more limited scientific literacy and numeracy are more concerned about climate change under certain circumstances than those with higher scientific literacy and numeracy. The CCT predicts that cultural and other values will trump the positive effects of education on some forest owners' attitudes to climate change. Here, using survey data collected in 2010 from 766 private forest owners in Sweden and Germany, we provide the first evidence that perceptions of climate change risk are uncorrelated with, or sometimes positively correlated with, education level and can be explained without reference to cultural or other values. We conclude that the recent claim that advanced scientific literacy and numeracy polarizes perceptions of climate change risk is unsupported by the forest owner data. In neither of the two countries was university education found to reduce the perception of risk from climate change. Indeed in most cases university education increased the perception of risk. Even more importantly, the effect of university education was not dependent on the individuals' value profile.

Conclusiveness resolves the conflict between quality of evidence and imprecision in GRADE.

OBJECTIVES: The objective of our article is to show how "quality of evidence" and "imprecision," as they are defined in Grading of Recommendations Assessment, Development, and Evaluation (GRADE) articles, may lead to confusion. We focus only on the context of systematic reviews. STUDY DESIGN AND SETTING: We analyze, with the aid of standard probabilistic and statistical concepts, the concepts of quality of evidence and imprecision as used in the GRADE framework. This enables us to point out some weaknesses in the relation between "quality of evidence" and "imprecision." RESULTS: The GRADE framework contains terms familiar from classical statistics, but these terms are used in nonstandard ways. Notably, "imprecision" does not have the meaning in the GRADE framework that it has in statistics, and the well-known table of "evidence levels" wrongly suggests that "quality of evidence" and "accuracy" express the same concept-they do not. CONCLUSION: We believe that "conclusiveness" rather than "imprecision" would be a suitable term to use when the question whether the CI excludes or includes certain critical margins is being addressed. Conclusiveness could also replace quality of evidence as the final step for a systematic reviewer.

Why resilience is unappealing to social science: Theoretical and empirical investigations of the scientific use of resilience.

Resilience is often promoted as a boundary concept to integrate the social and natural dimensions of sustainability. However, it is a troubled dialogue from which social scientists may feel detached. To explain this, we first scrutinize the meanings, attributes, and uses of resilience in ecology and elsewhere to construct a typology of definitions. Second, we analyze core concepts and principles in resilience theory that cause disciplinary tensions between the social and natural sciences (system ontology, system boundary, equilibria and thresholds, feedback mechanisms, self-organization, and function). Third, we provide empirical evidence of the asymmetry in the use of resilience theory in ecology and environmental sciences compared to five relevant social science disciplines. Fourth, we contrast the unification ambition in resilience theory with methodological pluralism. Throughout, we develop the argument that incommensurability and unification constrain the interdisciplinary dialogue, whereas pluralism drawing on core social scientific concepts would better facilitate integrated sustainability research.

Climate change: believing and seeing implies adapting.

Knowledge of factors that trigger human response to climate change is crucial for effective climate change policy communication. Climate change has been claimed to have low salience as a risk issue because it cannot be directly experienced. Still, personal factors such as strength of belief in local effects of climate change have been shown to correlate strongly with responses to climate change and there is a growing literature on the hypothesis that personal experience of climate change (and/or its effects) explains responses to climate change. Here we provide, using survey data from 845 private forest owners operating in a wide range of bio-climatic as well as economic-social-political structures in a latitudinal gradient across Europe, the first evidence that the personal strength of belief and perception of local effects of climate change, highly significantly explain human responses to climate change. A logistic regression model was fitted to the two variables, estimating expected probabilities ranging from 0.07 (SD ± 0.01) to 0.81 (SD ± 0.03) for self-reported adaptive measures taken. Adding socio-demographic variables improved the fit, estimating expected probabilities ranging from 0.022 (SD ± 0.008) to 0.91 (SD ± 0.02). We conclude that to explain and predict adaptation to climate change, the combination of personal experience and belief must be considered.

Misconceptions of positivism and five unnecessary science theoretic mistakes they bring in their train.

BACKGROUND: Positivism is sometimes rejected for the wrong reasons. Influential textbooks on nursing research and in other disciplines tend to reinforce the misconceptions underlying these rejections. This is problematic, since it provides students of these disciplines with a poor basis for reflecting on epistemological and methodological perspectives. It is particularly common for positivist views on reality and causation to be obscured. OBJECTIVES AND DESIGN: The first part of this discussion paper identifies and explains the misconceptions about positivism as they appear in two influential textbooks. The second part pinpoints five mistakes these misconceptions easily result in when the researcher adopts an epistemological and methodological standpoint.

Semmelweis's methodology from the modern stand-point: intervention studies and causal ontology.

Semmelweis's work predates the discovery of the power of randomization in medicine by almost a century. Although Semmelweis would not have consciously used a randomized controlled trial (RCT), some features of his material-the allocation of patients to the first and second clinics-did involve what was in fact a randomization, though this was not realised at the time. This article begins by explaining why Semmelweis's methodology, nevertheless, did not amount to the use of a RCT. It then shows why it is descriptively and normatively interesting to compare what he did with the modern approach using RCTs. The argumentation centres on causal inferences and the contrast between Semmelweis's causal concept and that deployed by many advocates of RCTs. It is argued that Semmelweis's approach has implications for matters of explanation and medical practice.

A philosophical account of interventions and causal representation in nursing research.

BACKGROUND: Representing is about theories and theory formation. Philosophy of science has a long-standing interest in representing. At least since Ian Hacking's modern classic Representing and Intervening (1983) analytical philosophers have struggled to combine that interest with a study of the roles of intervention studies. With few exceptions this focus of philosophy of science has been on physics and other natural sciences. In particular, there have been few attempts to analyse the use of the notion of intervention in other disciplines where intervention studies are important, such as in nursing research. One unintended consequence of this is that the relations between representing and intervening tend to be less understood outside the natural sciences. OBJECTIVES AND DESIGN: This article highlights a number of possible topics on which nursing science and analytic philosophy of science can fruitfully interact. The basic idea is simple. Building on a characterisation of interventions in terms of (i) what is intervened on and (ii) with respect to what, we suggest that interventions in nursing research typically are a blend of varieties belonging to the three dimensions of agency, epistemology, and ontology. The details of the blend determine the relation of the particular intervention study to traditional representational categories such as inductivism and hypothetico-deductive method, and have a bearing on its explanatory power and other more theory independent features of research as well. The framework we suggest should be relevant for nurse researchers who want to adopt a more general and analytically entrenched perspective on representing and intervening than the methodological boundaries in nursing research typically allow.