Promoting networks between evidence-based medicine and values-based medicine in continuing medical education

Abstract

Background: In recent years, medical practice has followed two different paradigms: evidence-based medicine (EBM) and values-based medicine (VBM). There is an urgent need to promote medical education that strengthens the relationship between these two paradigms. This work is designed to establish the foundations for a continuing medical education (CME) program aimed at encouraging the dialogue between EBM and VBM by determining the values relevant to everyday medical activities.

Methods: A quasi-experimental, observational, comparative, prospective and qualitative study was conducted by analyzing through a concurrent triangulation strategy the correlation between healthcare personnel-patient relationship, healthcare personnel's life history, and ethical judgments regarding dilemmas that arise in daily clinical practice.In 2009, healthcare personnel working in Mexico were invited to participate in a free, online clinical ethics course. Each participant responded to a set of online survey instruments before and after the CME program. Face-to-face semi-structured interviews were conducted with healthcare personnel, focusing on their views and representations of clinical practice.

Results: The healthcare personnel's core values were honesty and respect. There were significant differences in the clinical practice axiology before and after the course (P <0.001); notably, autonomy climbed from the 10th (order mean (OM) = 8.00) to the 3rd position (OM = 5.86). In ethical discernment, the CME program had an impact on autonomy (P ≤0.0001). Utilitarian autonomy was reinforced in the participants (P ≤0.0001). Regarding work values, significant differences due to the CME intervention were found in openness to change (OC) (P <0.000), self-transcendence (ST) (P <0.001), and self-enhancement (SE) (P <0.019). Predominant values in life history, ethical discernment and healthcare personnel-patient relation were beneficence, respect and compassion, respectively.

Conclusions: The healthcare personnel participating in a CME intervention in clinical ethics improved high-order values: Openness to change (OC) and Self Transcendence (ST), which are essential to fulfilling the healing ends of medicine. The CME intervention strengthened the role of educators and advisors with respect to healthcare personnel. The ethical values developed by healthcare professionals arise from their life history and their professional formation.

Figure 1

A Venn-Euler diagram of values. Values are the universe, while virtues and principles are subsets. The subset of virtue considers those values that refer directly to the healthcare personnel, their traits of character and decision-making. The subset of Principles expresses a normative procedure according to which actions can be guided to reach certain values [29].

Figure 2

Framework of the analytic methodology. In step 1, we used statistical analyses to examine the axiology of clinical practice (values in healthcare, work values, virtues in medical practice and three clinical vignettes posing ethical dilemmas) and the characteristics of participants prior to conducting the CME in clinical ethics. In step 2, we used qualitative content analysis of semi-structured interviews (SSIs) to examine reasons for values usage in clinical practice and axiology in the ethical discernment process prior to conducting the CME in clinical ethics. After quantitative and qualitative research questions were examined, these results were integrated based on the mutual validation model, which regards the search for convergent findings as validity indicators as the most important purpose of triangulation. We explored potentially strong connections between EBM and VBM using qualitative results, while we inferred the extent of the benefits of novel networks using quantitative results. After conducting the CME in clinical ethics intervention, we repeated the analyses (steps 3 and 4), and the full results were integrated.

Figure 3

Hierarchy of values in clinical practice in Mexico. Each of the charts shows the state of values before the intervention (n = 2,891). Deontological values are in blue, aretological values are in red, and utilitarian values are in green. The lower the values, the higher their level of importance.

Figure 4

Hierarchy of values in clinical practice before and after CME intervention. All the values presented statistically significant change before and after the intervention (Wilcoxon Signed Rank Test with Bonferroni's correction).

Figure 5

Ethical clusters found among Mexican healthcare personnel. Aretological values are A; deontological values are D; utilitarian values are U. Before (1) and after (2) the educational intervention.

Figure 6

Four high order values (Schwartz's theory) before and after CME intervention. Each row includes N = Nurses, M = Medical Doctors, HP = Others Healthcare Professionals. A = Administrative personnel. Spheres in red are females. 1 = Before and 2 = After educational intervention. A: Scatter plot in 3D. Openness to Change. Spheres representing post-CME intervention appear compacted. B: Scatter plot in 3D. Self-transcendence. Spheres representing post-CME intervention appear compacted. C: Scatter plot in 3D. Self-Enhancement. D: Scatter plot in 3D. Conservation.

Figure 7

Semantic networks. Keywords were identified with Atlas.ti 6.0 software. Words were sorted according to the frequency of their appearance in the interviews. The cut-off point, which divides the set of words into a high-frequency and low-frequency groups, was identified. Radial graphs explaining the frequency of appearance were created with MS Excel 2007. Red indicates before CME, and blue indicates after CME. A: Semantic Networks for Life History. B: Semantic Networks for Ethical Discernment. C: Semantic Networks for Healthcare Personnel-Patient Relationship.

Figure 8

Virtues of medical practice. *Denotes a statistically significant difference before and after the intervention (Wilcoxon Signed Rank Test with Bonferroni correction). Vertical lines tie the pair of values between which no statistically significant difference was found (Steel-Dwass All Pairs Comparison).