Hi Tammy, Glyn and everyone
A further thought: I think that you will agree that the success of medical care depends on doctors and patients working together. However, it is the patient who starts the process by asking for advice and who also controls it by agreeing or disagreeing with that advice.
Before the patient can agree in a process of informed consent, he or she (or a legal guardian) needs the answers to the following basic questions (and must ‘retain’ them, ideally by getting the answers in writing): (1) What actions have been agreed to? (2) For each action, what was the diagnosis (the title to the reasoning process leading to a prediction about the outcome after choosing various options)? (3) For each ‘diagnosis’, what was the ‘particular’ evidence (the symptoms, signs and test results used in the reasoning processes) connected to that diagnosis?
A more knowledgeable patient, or doctor giving a second opinion, would ask more detailed questions based on the answers to the above three basic questions. Some of these more detailed questions may be about the results of published RCTs. There would be many others too, for example questions to evaluate ‘general’ evidence from the literature about how the patient’s particular evidence matched those in published studies to assess the best way of selecting patients for a treatment, which tests can solve most quickly and cheaply the patient’s diagnostic problems and what pros and cons the patient was given when choosing between treatment options.
I think that those non-doctors working in EMB should take a lead in advising patients to ask the very basic questions (1) to (3) above. This would allow patients to work more effectively with doctors during SDM so that EBM can be put into practice more widely and consistently. Perhaps all patients should carry a little card bearing these questions.
Huw
Dr Huw Llewelyn MD FRCP
General Physician and Endocrinologist
Hon Fellow
Aberystwyth University
Mobile +447968528154
________________________________________
From: Tammy Hoffmann [[log in to unmask]]
Sent: 02 July 2013 07:43
To: Huw Llewelyn [hul2]
Subject: RE: Shared Decision Making Conference Lima
Hi Huw
Many thanks for suggesting this resource and for the approach you take. Nice to see SDM incorporated into the diagnostic process in this way.
Kind regards
Tammy
-----Original Message-----
From: Huw Llewelyn [hul2] [mailto:[log in to unmask]]
Sent: Tuesday, 2 July 2013 1:54 AM
To: Tammy Hoffmann; [log in to unmask]; [log in to unmask]
Subject: RE: Shared Decision Making Conference Lima
Dear Glyn, Tammy and all
I fully support the incorporation of SDM into EBM. SDM involves incorporating using the patient's own 'evidence' to predict which option will probably benefit that patient best. This 'evidence' is based on the patient's past personal experience and is combined with the collective, carefully documented experience of researchers studying groups of patients (which is what is usually regarded as the 'evidence' of evidence-based medicine). Any evidence based on past experience (of the patient or researcher) can be termed 'general' evidence, and evidence based on the patient's symptoms, signs and test results in a particular situation can be termed 'particular' evidence. These terms are based on 'particular' and 'general' propositions in logic.
The individual patient's current symptoms, signs and test results is an essential part of the total 'evidence' that is used to arrive at diagnoses and to choose the course of action that will probably provide the greatest benefit. So in order to be transparent about ALL the evidence that is used to share a medical decision with a patient, it is important to specify which symptoms, signs and test results were used to arrive at each diagnosis in that 'particular' patient and the resulting choice of treatment (see pages 9, 10 and 11 of Chapter 1 of the Oxford Handbook of Clinical Diagnosis http://fds.oup.com/www.oup.com/pdf/13/9780199232963_chapter1.pdf).
I have practiced and taught this approach to sharing and agreeing diagnoses and decisions and documenting them at the bedside and in clinics throughout my career. This approach and how to link each diagnosis and decision to the evidence used to make them is also explained in Chapter 1 of the Oxford Handbook of Clinical Diagnosis (see for example pages 12, 13, 16 and 17). I would therefore like to suggest the Oxford Handbook of Clinical Diagnosis as another resource that also promotes 'Shared Decision Making' at the point of care.
Huw
Dr Huw Llewelyn MD FRCP
General Physician and Endocrinologist
Hon Fellow
Aberystwyth University
Mobile +447968528154
________________________________________
From: Evidence based health (EBH) [[log in to unmask]] on behalf of Tammy Hoffmann [[log in to unmask]]
Sent: 30 June 2013 23:06
To: [log in to unmask]
Subject: Re: Shared Decision Making Conference Lima
Dear all
Thanks for your post Glyn. We couldn't agree more about the need for closer alignment of EBP and SDM.
One of the ways to promote the uptake of SDM is for teaching about SDM (and the skills needed to do this) to occur as part of EBP teaching (either in workshops or in more formal courses; at both the undergraduate level and for clinicians)
A small group of us (myself, Chris Del Mar, and Victor Montori) are planning to hold some discussions and a workshop about this issue at the Evidence-Based Health Care International Joint Conference in Sicily in October.
As part of this, we would like to gather together any existing resources which people are already using to teach clinicians (and student clinicians) how to talk with patients about evidence and how to facilitate shared decision making.
We're aware of some resources, but suspect there may be many more and often ones that are only used locally. We'd be grateful if you could email these to me. After the conference, we'll happily share the compiled list of resources (and the resources themselves where possible) and a summary of the issues discussed with the list.
Many thanks
Tammy
Associate Professor Tammy Hoffmann
Centre for Research in Evidence-Based Practice Faculty of Health Sciences and Medicine Bond University Gold Coast, Queensland, Australia
Tel: +61 7 5595 5522
www.crebp.net.au
http://works.bepress.com/tammy_hoffmann/
-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Glyn Elwyn
Sent: Thursday, 27 June 2013 9:54 PM
To: [log in to unmask]
Subject: Shared Decision Making Conference Lima
Dear Colleagues
Just joined this listserv - you may have already seen this - so apologies for repeats.
A Mayo-led team (Montori/LeBlanc) organised the 7th conference in Lima (terrific by the way), where Gordon Gyuatt gave an excellent keynote.
Keynote: EBM needs SDM needs EBM with Dr. Gordon Guyatt
http://isdm2013.org/video-archive/
Others from the EBHC community gave workshops. Interesting to reflect in 2013 how I got into this SDM area from a kick-off in Oxford-based week-long events many years ago, where Greenhalgh, Milne, Sackett, and many others were strong on the need for evidence etc.
High time even more bridges were built between EBHC (sample based data) and the need to respect individual, yet informed, preferences (personal level decision making).
There was evidence of culture dissonance for sure - the word 'recommendation' - weak or strong - was under debate in one workshop where GRADE was under the spotlight. Yet the mood was one of a genuine attempt to integrate these population / individual stances somehow. Looking forward to those conversations.
Glyn
Professor Glyn Elwyn
BA MB BCh MSc FRCGP PhD
[log in to unmask]
The Dartmouth Center for Health Care Delivery Science | USA The Dartmouth Institute for Health Policy and Clinical Practice | USA Scientific Institute for Quality of Healthcare | University Nijmegen Medical Centre | Netherlands.
Cochrane Institute for Primary Care and Public Health | Cardiff University | UK @glynelwyn Twitter
glynelwyn Skype
+1-603-646-2295 Desk
+1-603-729-6694 Cell
+1-603-646-2553 Robin Paradis Montibello
|
