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Dear All I agree whole heartedly with the threads of this discussion. The technical aspects involved in EBM are difficult enough. Incorporating EBM into real-world decision making jointly with patients on a fuly informed basis seems to me to be still, if not in its infancy, barely into a baby walker. Two nmemonics, no doubt familiar to UK GPs preparing for Membership of the Royal College of General Practitioners. Are these helpful / well known? 1. (Usually fairly early in the consultation). ICE (Seeking information) I Ideas e.g. "What do you think might be causing this?" - obviously looking for the patients perspective, and important in itself but sometimes vital in arriving at the right diagnosis. I saw a video consultation recently with a patient with a cough. Without asking the question the doctor moves right into the antibiotics / no antibiotics debate. However, when the above question was asked, the following was the response "Well, I work with asylum seekers and quite a few of them have TB....and I have been having these dreadful night sweats....". C Concerns Often just an open question. e.g. "This must have been worrying you" followed by some silence. Can sometimes elicit remarkable insights into some agendas that otherwise we'd have no idea were present. E.g. "If this is something serious then I've a child with Down's syndrome.....". E Expectations This moves more into Paul's territory, but not quite because this not about giving information. Before that occurs, this it is an attempt to uncover what the patient thinks we can do. E.g. "What do you know about this? What do you know about how this is treateed these days?" I apologise for the trite phrases. Everyone can find their own that work for them. 2. (Usually towards the end of the consultation). OICJ (Giving information) O Options "We could do X or Y or Z" I Implications "If we do X (and this could be nothing as in Paul's model), then its likely that...... On the other hand if we do Y........." C Choice "On balance, I'd usually choose Y". Often precedded by an interim step when the patient is asked what they think about those choices. J Justification Sometimes not required, but if it is.... E.g. "Here's a picture that explains the limited benefits of antibiotics in middle ear infections. It shows, a hundred children who have ear inections, and - to the best of our knowledge - what happenns to them without antibiotics. Let me take you through this...." ...."And here's another picture which explains the benefits of antibiotics.....and finally here's a third picture which shows how many extra children are made ill by side effects from antibiotics. What do you think is the best we can do here?". The skills required here are, as yet, still in development. But we could perhaps envisage the norm being clinicians being able to understand a summary of evidence from a trusted source. I agree that for the majority critical appraisal is mostly about understanding what someone else has done, because (assuming you've done it really well), if you read and critically appraised a recent paper all you've done is read that paper. What if there are another six in the literature that say we should treat patients in an entirely different way? If the clinician can understand the summary, then there's usually a need to turn those results from absolute to relative and then into "If we were to think of a hundred people like you, then xx will be ok over the next 5 years with no treatment. However, that means yy will have...." As a skill, consulation translation "from evidence to meaningful information for patients" is really not there at the moment - at least based on my experiences in the UK. Feedback would be much appreciated. Best Wishes Neal Neal Neal Maskrey. Medical Director, National Prescribing Centre, 70 Pembroke Place, Liverpool L69 3GF. Tel: 0151 794 8135. e-mail: [log in to unmask]