Dear All,
Very interesting comments - the two-way communication is difficult when
we are short of time and words mean different things to different folk.
I don't think there is any easy way out for EBMers or non-EBMers.
But a process we suggested in the book "Clinical Thinking" recently was
to use the following three steps:
1. What would happen if we did nothing?
We may begin explaining the disease by saying something like: “Do you
know about X? OK, well let me explain. If we did nothing the usual
course of the illness is to …”
2. Explain what the options there are:
We next list and explain the main management options, for example:
“There are three common things we can do about this: a pill, or surgery,
or we can let it take its course (natural history)”.
3. Check the patients expectations and ideas:
We should know if the patient has tried any of the options, or has prior
knowledge and expectations about them. For example, “Have you tried
anything yourself, or did you have a preference for one of those
options?” At this point a dialogue may ensue about the pros and cons of
the various options, or the patient may simply ask what you recommend.
I pretty much follow this approach in my own clinical practice, but I'd
be interested to know of other approaches to this difficult step,
Paul Glasziou
Bill Cayley, Jr wrote:
> I would agree that the patient preference piece is
> HARD to sort out. And, it's easy enough to list
> illiteracy, differing values, different language (and
> perhaps other issues) as parts of the barrier to
> understanding patiet preference. BUT, in each real
> life, case-by-case situation, how easy is it really to
> understand which (ones) of these are operative.
>
> In clinical practice, how often to we have the time
> and patience to fully sort out whether someone's lack
> of understanding is due to language or intelligence or
> comprehension? Or how about sorting out whether a
> patient's seemingly poor choice is due to different
> values from mine, or a communication barrier, or lack
> of information or lack of intelligence?
>
> There is quite a body of literature out there on
> "reflective" practice, and I think there could be some
> fertile ground for studying how insights from that
> work can inform the clinical practice of EBM.
>
> Bill Cayley MD
>
> --- Diana Rodríguez Hurtado <[log in to unmask]>
> wrote:
>
>
>> Dear Colleagues:
>> About EBM, I am defender of EBM, but in the topic
>> about Patient values and preferences in order to
>> involve the patients in the decision making process,
>> I have a commentary :
>> Don´t you think that sometimes you can find barriers
>> for example in developing countries? Example, when
>> you are in front a patient who is analphabet or that
>> belong to ethnic group whose lexicon we don´t know,
>> with the risk that the patient take an erroneous
>> decision by ignorance.
>> Some day I had listened:
>> "A man who is not informed, he can not have opinion,
>> and a man who has not opinion, he can not take
>> decision" .
>> I would like to receive your answers.
>> Sincerely.
>>
>> Diana Rodriguez M.D.
>> Associate Professor Faculty of Medicine "Universidad
>> Peruana Cayetano Heredia".
>> Master in Clinical Epidemiology.
>> Member of INCLEN (International Clinical
>> Epidemiology Network).
>> Lima , PERU.
>> e-mail [log in to unmask]
>>
>> [log in to unmask]
>>
>>
>>
>
>
> Bill Cayley, Jr, MD MDiv [log in to unmask]
>
> Augusta Family Medicine Home Address
> 207 W Lincoln 3433 McIvor St
> Augusta, WI 54722 Eau Claire, WI 54701
> Work: 715-286-2270 Home: 715-830-0932
> Page: 715-838-7940 Cell: 715-828-4636
>
>
--
Paul Glasziou
Director, Centre for Evidence-Based Medicine,
Department of Primary Health Care,
University of Oxford www.cebm.net
ph +44-1865-227055 fax +44-1865-227036
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