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Thanks, Amit but isn't the key issue the lack of time- the most precious commodity of our times? I certainly am capable of taking care of uncomplicated diabetes, COPD, hypertension etc but I stick to hem-onc problems since I don't have time to look up the latest recommendation and hence I end up referring the patient. If I have more time I would be able to solve more than 1-2 patient's problem, which is what typically a subspecialist tend to manage. A friend of mine suggested that a solution for contemprary fragmentation of care is to limit the number of patients per physician (akin to what was done for doctors in training). A too radical idea? But, it raises the important question : would patients be better served with one doctor (who has enough time) taking care of their multiple problems, or multilple subspecialists? ( I am not talking about one time consults/procedures; I am referring to management of chronic problems). And, I am looking forward to seeing how the integrated systems that Jim and Rakesh mentioned will work in practice- at the moment the system is all about managing time/ work flow and less about providing the best care). Ben On Aug 31, 2009, at 8:49 AM, "Ghosh, Amit K., M.D." <[log in to unmask]> wrote: > Dear Ben, > The ABMS/ ABIM exam system tests for knowledge not skills. Even if > they > measured skills they would have to limit to one or few areas that can > never match the complexity of clinical practice. > One specialty that got into trouble because of the proliferation of > information, unrealistic expectation and constant scrutiny is Gen. > Medicine. This has resulted in shrinking interest and enrollment by > medical students for Gen. Med ( despite visions of Oslerian > professionalism and bed side skills) and exodus to other areas by > individuals trained in Gen. Medicine. Shrinking pay scale, diminishing > respect by other subspecialty and insurmountable pressures by public > and > press are also close contributors. By the way this group of physicians > are superbly trained to dissect any article and are often the trainers > in any EBM sessions/ workshops. This is not EBM's problem though. > Several of these issues could not be foreseen. > Hence, just because you know to read an article doesn't mean you will > not get a consult. There more on the plate than critical appraisal and > filling the blanks of an EBM worksheet. It might be considered > quixotic > in a way to just read an article and acting out on your own. EBM > however > does make someone catch up to any new thing rapidly, the application > of > the article effectively however needs another 3-5 years of training. > Amit Ghosh > Mayo Clinic, Rochester > > > -----Original Message----- > From: Evidence based health (EBH) > [mailto:[log in to unmask]] On Behalf Of > Djulbegovic, > Benjamin > Sent: Monday, August 31, 2009 7:20 AM > To: [log in to unmask] > Subject: Re: EBM and increasing requests for the use of consultants... > > No doubt what you described is likely one of the reasons for > increasing > use of referrals. However, our (educational) organizational > structure is > such that we are still insisting on individual physicians proficiency > (e.g. typically in the US you need at least 30-50 annual CME, take > your > specialty exam every 7-10 years depending on your specialty etc). So, > tremendous effort goes into building your individual knowledge base in > order to refer your patient to a number of other consultants? > ben > > > -----Original Message----- > From: Piersante Sestini [mailto:[log in to unmask]] > Sent: Monday, August 31, 2009 2:41 AM > To: Djulbegovic, Benjamin > Cc: [log in to unmask] > Subject: Re: EBM and increasing requests for the use of consultants... > > I am not sure whether the number of referrals did increase in Italy > over > the last 10 years, but they certainly did enormously over the last > 20 or > 30 years. > As you suggests, this has more to do with the way the health industry > works that with the availability of systematic reviews and guidelines. > Medicine is less and less seen as an individual business and more as a > collective, interprofessional teamwork. > The reason is probably the same that lead to the success of EBM: the > enormous increase in information to be managed and of needed skills. > > If a physician has to care for many patients with a large variety of > possible disorders, she cannot get enough expertise on most of them to > be confident to treat them, even if she has the time of reading some > relevant guidelines: you don't get skills by reading a guideline. Of > course, no conscientious physician would treat a patient just based > on a > quick browsing through a guideline and a few checklists, without > having > a good confidence of her skills and understanding of the underlying > condition. > > Thus, IMHO guidelines are more likely to be useful to improve the > practice of different teams, than to be used by every single physician > of each team. > > regards, > Piersante Sestini > > > > > > > Djulbegovic, Benjamin wrote: >> >> Dear all >> >> It has been my impression that the rise of EBM (along with >> proliferation of systematic reviews (SR) and guidelines, critical >> attitudes toward health care claims etc) has not reduced the requests >> for the use of experts (consultants). Paradoxically, the last decade >> has seen ever increasing use of consultants. In the US, at least, an >> explanation for this trend in ever increasing requests for "consults" >> is related to the incentives to see more and more patients with the >> consequence that doctors do not have time to look up the guidelines, >> SRs etc. As a result, doctors just ask for yet another consult. I >> wonder what has been trend in other countries? Do physicians >> elsewhere >> also consult more often than, say, 10 years ago? If yes, why is this >> so? What is the purpose of developing all these guidelines if only >> experts will use them (and who will typically deviate from the >> guidelines)? What is an average number of physicians that the >> patients >> typically see? >> >> I would appreciate some thoughts on this issue, which is actually not >> a trivial one as it may appear on the first blush. >> >> Thanks >> >> ben >> >> Benjamin Djulbegovic, MD, PhD >> >> Professor of Medicine and Oncology >>