I would encourage you not to think in terms of attack and defense but to
think what underlies their potential objections to and rejections of EBM.
What I have learned is that people defend two things: 1. the value of their
OWN judgements (threatened by guidelines and other documents handed down
from people that REALLY know what they are doing), and 2. the value of
individualizing care (as oppose to treat all patients with diabetes
according to the guidelines). One initial point of mutual understanding is
to acknowledge the perils of EBM practice in the abcense of expertise,
thorough consideration of the facts, common sense, and any consideration of
the patients values and preferences.
To this effect I start my sessions presenting a Venn diagram that has
appeared in several of RB Haynes writings and (the one I use) in Annals of
Internal Medicine in 1991 in an article by Davidoff, Mulrow, and others on
systematic reviews and the chain of evidence. This diagram shows how
evidence is but one of multiple factors to be considered in clinical
decision making.
Then I tell them that this small area is very important and that is why we
will concentrate on that area for today and express wishes for discussion on
the other aspects later in the session.
You can further this point by reviewing the comments expressed in the Users'
Guides XXV published in JAMA that reviews these issues.
This approach allows you to concentrate on the good aspects of EBM and put
it in its real context without having to put yourself in a defensive mode -
a stressful situation that will be picked up by the audience and encourage
them to tear you appart. A case where solid high quality evidence does not
apply can help illustrate the point. You can also illustrate a great
insight provided by consulting a colleague on a particularly complicated
case. Finally, you can comment on the dismay of one of your students coming
back from searching and saying 'there is no evidence' and how you showed her
the way to nearest phone to call the local specialist (which may allow you
to discuss the hierarchy of evidence at that point).
Once inside of them you hit them hard with the best EBM (evidence ballistic
missiles) you've got. You were never in a defensive mode... you were always
inside a Troyan horse, but a transparent and truthful one.
Hope this is helpful,
Victor
-----Original Message-----
From: K.Hopayian [mailto:[log in to unmask]]
Sent: Wednesday, March 21, 2001 4:35 AM
To: [log in to unmask]
Subject: Teaching in hostile territory
I am booked to give an introductory talk to two groups of general
practitioners in this part of England, East Anglia. The first is a group of
GPs attending an annual refresher course, the second a group of trainers and
their trainees (called registrars in England). Both groups contain
individuals hostile to EBM (though none have had direct exposure, I
suspect).
My plan is to use *educational aikido* - that is, let them attack and I will
use their own force or weight to floor them. I believe I can predict what
they will say and so have some examples to give to illustrate that EBM is
not the monster they believe and that it can help answer questions that
arise in general practice.
I have never done this before so I wonder if any of you have experience I
could benefit from?
--
Best wishes, Kev Hopayian
GP, Leiston, Suffolk, UK
Web site: http://www.suffolk-maag.ac.uk/kevhop
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