Amit, I entirely agree. The application of best evidence, taking into
account the patient's wishes, preferences, etc., means that subjective
judgement will always be a part of medical decision-making and thus open to
challenge, especially when the inevitable bad outcomes occur.
EBM perhaps has a role in helping to shape the expectations of our patients
as over-optimistic expectations are often the root cause of patient
complaints and litigation. Pressurising the mainstream media to use the
principles of EBM in reporting healthcare issues would probably prove a good
investment.
Paul.
On 3/11/04 22:21, "Ghosh, Amit K., M.D." <[log in to unmask]> wrote:
> Paul,
> I agree with your observation.
> We recently reported on the issue of using EBM in moments of uncertainty.
> There are no easy answers. Though knowing when there is inadequate or
> conflicting evidence needs a honest reappraisal and not an unmindful
> application of evidence.
>
> On the challenges of using evidence-based information: the role of clinical
> uncertainty.
> Ghosh AK. J Lab Clin Med. 2004 Aug;144(2):60-4.
>
> The Division of General Internal Medicine, Mayo Clinic College of Medicine,
> Rochester, MN 55905, USA. [log in to unmask]
>
> Evidence-based medicine helps physicians appraise the latest and best evidence
> and incorporate patient's values in reaching a shared clinical decision.
> However, many decisions in medicine are made in the paucity of best evidence.
> Medical uncertainty remains inherent in clinical practice and contributes to
> significant variability in the way physicians and patients manage medical
> problems. Physicians and patients have varying degrees of tolerance for
> uncertainty. Intolerance to uncertainty among physicians results in increased
> test ordering tendencies, variability in medical treatment, failure to comply
> with evidence-based guidelines, and even guide career choices. Factors that
> result in the variability of physicians' interpretation of an effective
> treatment include: patient factors (prioritizing some factors over others),
> physician factors (lack of knowledge, lack of resources, medical uncertainty),
> and environmental factors (limitation of time and practice). Several approach
> es that have been found useful in implementing evidence in clinical practice
> include: sending reminders to prompt physicians to perform patient-related
> clinical activities, introducing computer information systems to support
> practice, and using interactive education interventions to teach newer skills
> and challenge negative attitudes. Passive educational approaches, like
> dissemination of guidelines and didactic lectures, are usually less useful in
> changing behavior. Among the techniques found to be useful for managing
> uncertainty are shared decision making, meticulous history taking, and
> physical examination, excluding worrisome differential diagnosis and
> establishing trust in patients. The role of future studies in assessing the
> outcome of multiple evidence-based strategies in situations of medical
> uncertainty remains to be explored.
>
> Amit K. Ghosh, MD, FACP
> Consultant, Internal Medicine
> Mayo Clinic College of Medicine , Rochester
> Phone:507-538-1128
> Fax: 507-284-4959
>
>
>> -----Original Message-----
>> From: Evidence based health (EBH)
[SMTP:[log in to unmask]]
>> On Behalf Of Paul Flynn
>> Sent: Wednesday, November 03, 2004 3:30 PM
>> To: [log in to unmask]
>> Subject: Re: Medical malpractice & EBM
>>
>> I think that EBM may be a bit of a false dawn in the realm of medical
>> malpractice/negligence. Firstly there are so many gaps in the evidence
>> available to doctors that they will always have to use their own judgement.
>>
>> Secondly, although there may be evidence regarding management of a
>> situation, the diagnosis may rely on subjective interpretation e.g.
>> Diagnosis of fetal acidosis in labour with CTG. In my experience of Risk
>> Management in Obstetrics, knowledge of criteria for interpretation of CTGs
>> is not synonymous with correct interpretation and appropriate action.
>>
>> I do think that the sooner we move away from the situation where courts rely
>> on partisan 'experts' and use professional bodies who create evidence-based
>> guidelines.
>>
>> Paul.
>>
>> --
>> Mr Paul M Flynn MRCOG
>> Clinical Director Obstetrics & Gynaecology, Swansea NHS Trust
>> +44 1792 285687 Fax: +44 1792 285874
>>
>>
>> On 3/11/04 19:42, "Dean Giustini" <[log in to unmask]> wrote:
>>
>>> Here's a question posed today: is one answer to the complex issue of>
>>> rising medical malpractice in Canada, the United States and the UK,>
>>> broader and more meaningful adoption of the principles of EBM?
>>>
>>> Of course, finding the evidence is a critical part of the practice of
>>> EBM. However, complete and flawless evidence is not enough to make valid
>>> and valuable treatment choices.
>>>
>>> If the interpretation of the evidence is not logically sound or if it is
>>> used uncritically, a patient could be harmed. Harm might also occur by a
>>> logically flawless use of poor or poorly evaluated evidence.
>>>
>>> Thank you for your responses to me, offline.
>>>
>>> Dean Giustini, Branch Librarian
>>> University of British Columbia
>>> Biomedical Branch Library
>>> Vancouver General Hospital - Heather Pavilion
>>> Vancouver Canada
>>> (604) 875-4505
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