The article was well written, and I plan to use it in teaching with medical students - who continue to be over-awed by "expert opinion" (in my opinion!)
BC
Bill Cayley, Jr, MD MDiv
Work:
Augusta Family Medicine
207 W Lincoln, Augusta, WI 54722
Tel: 715.286.2270
Pager: 715.838.7940
Home:
3604 Sharon Drive, Eau Claire, WI 54701
Tel: 715.830.0932
Mobile: 715.828.4636
A cheerful heart is good medicine... (Proverbs 17:22)
--- On Thu, 5/19/11, Rakesh Biswas <[log in to unmask]> wrote:
From: Rakesh Biswas <[log in to unmask]>
Subject: Re: insolvable uncertainty and shared decision making
To: [log in to unmask]
Date: Thursday, May 19, 2011, 10:33 AM
Thanks Ben and Ash for this timely article on 'indication creep' in JAMA which was definitely an excellent extension of the discussion that we enjoyed in the past few months and thanks Mayer for pointing it out. On Ash's point about patient driven health care it must be recognized that health care practically can never be just patient-driven as long as there are health professionals and other stakeholders representing other equally ( if not more) vital forces that drive health care. As Maurice Bernstein from 'Bioethics International' puts it ( although i can't be sure if this was exaclty what he meant..copying it to him as well for clarification), possibly patient autonomy and 'health professional paternalism' are two sides of the same coin? What health care possibly requires is transparency in 'information flow' that can create a democratic ecosystem (which Ben seems currently resigned to accept as
the only workable solution)? This may improve health outcomes in direct proportion to the heightened shared learning between all these stakeholders? :-) warm regards, rakesh
On Thu, May 19, 2011 at 2:37 AM, Ash Paul <[log in to unmask]" rel=nofollow target=_blank ymailto="mailto:[log in to unmask]">[log in to unmask]> wrote:
Dear Ben and Mayer,
I agree with you both that patient centred care means involving patients in shared decision-making.
Infact there is a major work-stream on this topic in the NHS led by Dr Steve Laitner with Neal Maskrey from this Group having a big input into the group.
As a commissioner of healthcare, I'm all for shared decision making and all for patient centred care. However, I do have qualms about patient-driven health care. Inadequately knowledgeable patients getting distorted/wrong information from the wrong sources may want healthcare but that does not automatically mean that they need it. In a finitely funded and publicly funded healthcare system like the NHS, it is very important to distinguish between healthcare needs and healthcare wants, otherwise we will end up with financial insolvency. I have written in somewhat detail about this issue in a previous email to this group.
I've just been reading a financial report from the USA that at the present rate of healthcare spending, the US Medicare Hospital Fund will become bankrupt by 2024, a full 5 years earlier than originally predicted (https://www.cms.gov/ReportsTrustFunds/downloads/tr2011.pdf). Clinicians all over the world absolutely need to grasp the nettle and start spending healthcare monies rationally and with circumspect, while at the same time involving their patients in all aspects of decision-making. They are still recognised with respect by the general public as the wise stewards of healthcare resources. Because if they don't, in the face of healthcare bankruptcy, they will have politicians and faceless bureaucrats like myself telling them what to spend treatment monies on.
And then they will only have themselves to blame for their fall from grace.
Both Ben and I would like to express our gratitude to the members of this group, whose thoughts on these issues we have tried to distill into this JAMA article. In the article itself, we have also acknowledged the valuable contribution of this group.
The JAMA article can be accessed at:
Regards.
Ash
Dr Ash Paul
Medical Director
NHS Bedfordshire
21 Kimbolton Road
Bedford
MK40 2AW
Tel no: 01234897224
From: "Djulbegovic, Benjamin" <[log in to unmask]" rel=nofollow target=_blank ymailto="mailto:[log in to unmask]">[log in to unmask]>
To: [log in to unmask]" rel=nofollow target=_blank ymailto="mailto:[log in to unmask]">[log in to unmask]
Sent: Wednesday, 18 May 2011, 12:38
Subject: Re: insolvable uncertainty and shared decision making
Dear Mayer
Thanks for reading the paper. Since, as pointed out in our article, the problems that arise from irreducible uncertainty-->inescapable errors--> unavoidable injustice belongs to a class of the problems that do not have adequate technical solutions, I indeed believe that shared decision-making (at individual AND most importantly at societal level) is probably the only way to minimize the consequences of imbalance between false positives vs. false negative decisions. It is like democracy- it is not perfect, but because we tend to understand the rules of the game ( and don't see an alternative to it), most of us embrace it.
Ash may wish to add to my response
best
Ben
Dear Ben:
Thank you for your superb paper in the current issue of JAMA:
From Efficacy to Effectiveness in the Face of Uncertainty. Indication Creep and Prevention Creep.
My question to you: in the face of insolvable uncertainty, don't you think that shared decision making might be one potential solution to reduce overuse (as shown by empiric evidence – see recent BMJ discussion http://www.bmj.com/content/342/bmj.d2117.full) while respecting individual's anxious request for more – also in a more just distribution of care?
Best,
Mayer
Mayer Brezis, MD MPH
Professor of Medicine
Director, Center for Clinical Quality & Safety
Hadassah Hebrew University Medical Center
Jerusalem, Israel
Office phone 02-6777110
Cellular 050-787-4596
Fax 02-643-9730
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