While we are talking about the fact that patients need to be informed about their medical care, strangely recent evidence shows that not all patients want to know actively participate in medical decision making! Though they want to know the available treatment choices more than half wanted their physicians to make the decisions for them. We need to understand that patient vary in their ability to understand and not all of them understand using the same modality.
Here is the abstract.
Journal of General Internal Medicine
Volume 20 Issue 6 Page 531 - June 2005
Not All Patients Want to Participate in Decision Making
A National Study of Public Preferences
Wendy Levinson, MD1, Audiey Kao, MD, PhD2, Alma Kuby, MBA3, Ronald A. Thisted, PhD4
Background: The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation.
Objectives: 1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people's preferences for participation in decision making.
Design And Participants: A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N= 2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences.
Main Results: Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined.
Conclusion: This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.
That is were EBM + experience can help.
Using an uni-dimension paper only format to present risks (i.e., RR, NNT)maynot suffice for all.
Amit K. Ghosh, MD, FACP
Associate Program Director
General Internal Medicine Research Fellowship
Mayo Clinic
W-17 B, GIM
200 1st ST. SW
Rochester, MN
507-538-1128 (Phone)
507-284-4959 (Fax)
-----Original Message-----
From: Bruce Arroll [mailto:[log in to unmask]]
Sent: Tuesday, August 09, 2005 2:05 PM
To: 'Ghosh, Amit K., M.D.'; [log in to unmask]
Cc: 'Stephen Buetow'
Subject: RE: Is asking focussed clinical questions a waste of time?
Dear EBM list
I am sympathetic to amit's comments. Even when the answer is found there is
still a clinical context in which to apply the information. For example
there is no RCT evidence that screening for prostate cancer with psa
improves outcome. RCTs of patients with symptomatic prostate symptoms do
benefit from total prostatectomy. It would be a brave clinician to
absolutely forbid the use of psa for a particular patient. The patient still
needs to be fully informed and it is difficult to get that sort of message
from medline or indeed the electronic clinical textbooksi.e the context. We
are encouraging our students in how to interpret clinical texts such as
uptodate.com and dynamicmedical.com
Regards
Bruce
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Ghosh, Amit K.,
M.D.
Sent: Wednesday, 10 August 2005 4:52 a.m.
To: [log in to unmask]
Subject: Re: Is asking focussed clinical questions a waste of time?
Thanks Ben.
EBM is here to stay but we are constantly forced to challenge almost all
aspects of its
Tenets.
The 5 A's recommended by Chris De Mar, Paul and Dan from last year's BMJ,
i.e.,
Ask, access, appraise, apply and assess help in conceptualizing EBM, but it
appears from current research that several of the tenets of EBM would be
considered theoritical unless studied using the right methods( qualitative,
educational research, complexity science, etc.). Applying quantitative
methods may not adequately answer some of the questions.
We have found problems with applying facts all the A's at the field level,
and for residents often UpToDate remains the fall back mechanism as they are
unable to find answers quickly. Brian Haynes 4 S model is applicable though
Decision aids are far from reality at presnet.Role modelling is also lacking
in most centers.
Lots of material get published under the rubric of EBM and that remains a
big issue.
I guess all of us are looking and working towards the next big break of, how
to use EBM in clinical practice in a reliable, and consistent basis.
In the end we might be producing more physicians who are expert at critical
appraisal but fall short in application of the information to their patients
and result in variability of care. One can never treat a patient just by
appraising a paper or knowing the evidence, the confidence comes with
experience , a teachable skill called' meta-cognition,' in the ER
literature. It would be interesting to get others thought on how they use
EBM in clinical practice.
Amit K. Ghosh, MD
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Djulbegovic,
Benjamin
Sent: Tuesday, August 09, 2005 11:28 AM
To: [log in to unmask]
Subject: Re: Is asking focussed clinical questions a waste of time?
not surprised at all- PICO is a normative concept, but MEDLINE or other
major databases have not been developed to meet this requirement (I
understand that the Cochrane Database will try to accommodate PICO concept,
but I am not sure how far it is in development)
Benjamin Djulbegovic, MD,PhD
Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute
at the University of South Florida
Department of Interdisciplinary Oncology
SRB #4, Floor 4, Rm #24031 (Rm# West 31)
12902 Magnolia Drive
Tampa, FL 33612
Editor: Cancer Treatment Reviews (Evidence-based Oncology Section)
http://www.harcourt-international.com/journals/ctrv/
e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/
phone:(813)979-7202
fax:(813)979-3071
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]]On Behalf Of Ben Skinner
Sent: Tuesday, August 09, 2005 11:34 AM
To: [log in to unmask]
Subject: Is asking focussed clinical questions a waste of time?
Dear all,
I have recently come across a piece of research by G Cheng looking at
whether
there is a significant correlation between clinicians asking focussed
clinical
questions (i.e. PICO format) and the success they have at finding the
information they need.
The reference is:
Cheng GYT (2004). A study of clinical questions posed by hospital
clinicians.
Journal of the Medical Library Association, 92(4), pp. 445-457.
The conclusion that Cheng comes to is that whether clinicians structure
their
query as a question or statement has no effect on their satisfaction with
the
results, and neither does their use of the PICO structure. If this is true,
it
strikes me as something that should have a big effect on the way people
practice
and teach EBP. But I'm not sure that it's true.
I was wondering if anyone else out there had come across this paper, and
whether
they had any comments? Has anyone thoroughly appraised the article? My
critical appraisal skills are not insignificant, but I don't have a research
background so tend to come unstuck once I reach a certain point. I suspect
there are some flaws with the validity of the conclusion, but I would love
to
hear some viewpoints from those more experienced than me.
Thanks for your help,
Ben.
Ben Skinner
Evidence-Based / Knowledge Management Librarian
The Library
Audrey Emerton Building
Royal Sussex County Hospital
Eastern Road
Brighton BN2 5BE
(01273) 523 307 / RSCH x3307
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