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G'day!

I think there's always been a tension, and it's always been a debate. When
I first became involved in this area I was a consumer advocate, and my
interest was also to a large extent based on my concern.

Certainly, my concerns were one of the main reasons I got involved in
establishing the Cochrane Collaboration a couple of decades ago: I had
hopes of playing a role into reducing the harm to consumer choice arising
from people losing access to services because of one (or a few)
researchers' subjective judgments & interpretations of evidence. That's one
of the consequences of those upstream applications of evidence. I wrote
something about whether consumers and EBM were allies or
enemies<https://www.mja.com.au/journal/2000/172/1/allies-or-enemies-evidence-based-medicine-and-consumer-choice?0=ip_login_no_cache%3D7074101b7247589113a9b6b920803bcc>many
years ago - came then to the position that it could go either way. It
depended on how patient-centred the evidence is, to a large extent, I
think.

We don't really know whether the results of EBM are beneficial: we believe
it and assume it's better than the alternative, but that itself has not
been tested. There are plenty of visible adverse
effects<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC524578/>-
sometimes practice wheeling about in this direction and that in
response
to evidence, ending up back where non-EBM practitioners always were, for
example. But people usually concentrate on the anecdotes of harm from NOT
being evidence-based, and quote anecodotal cases where EBM helped. On
balance, we just believe it's logical to assume that there's a net benefit
because science is meant to be self-correcting. But we don't know that,
because systematic reviews themselves can at times end further scientific
enquiry or channel it certain ways.

Whether EBM as a system was evidence-based was discussed a lot in
conjunction with a special BMJ issue in 2004: at the time, I think the
consensus was that we didn't have an evidence base for the system. I don't
think that's changed, has it? Certain aspects are tested in RCTs (often
without the hoped-for results), but not the whole. I'm not saying it needs
to be, but its effect on either making medicine more or less
patient-centered would certainly be one of the outcomes of great interest.

Hilda







On Wed, May 8, 2013 at 7:42 AM, Neal Maskrey <[log in to unmask]>wrote:

>  >> I would like to argue that person-centred care is at the centre of
> the EBM definition but EBM is not explicitly within definitions of
> person-centred care.****
>
> ** **
>
> Good question! ****
>
> ** **
>
> Is this reasonable? Yes! ****
>
> ** **
>
> But I’ve always found patients and the public entirely receptive to
> incorporating evidence into person-centred decision making about their
> care. After all, what is the alternative?****
>
> ****
>
> What I might gently add is that it seems to me there are 4 settings to get
> from evidence / information to informed individual decision making. ****
>
> ** **
>
> The settings, sequentially  I’d name as research, national guidance, local
> policies, and individual decision makings (RNLI). ****
>
> ** **
>
> EBM/P has focussed huge efforts at the first translation from research to
> “national guidance”. Discussions on this group are dominated by this – and
> very helpful they are. However, there is relatively little effort expended
> on the second translation from that guidance into local policies. Then
> there’s a relatively small amount of effort going into supporting
> evidence-based, shared decision making at the individual consultation
> level, but this is miniscule compared with the guidelines and technology
> appraisal effort. As Kev says, the issue is recognised but we still are
> woefully short on the “how to do it”. Adoption of evidence is arguably
> limited by this skewed effort, and by the lack of recognition that it takes
> a lot more than the first translation. ****
>
> ** **
>
> I think that RNLI model is useful, at least to me, when thinking about the
> journey from evidence to individual care. Each of the settings have their
> own paradigm - and translations to help move through what is often a far
> from an orderly, logical and sequential progression each require (very)
> different approaches, skills, attitudes, tools etc. ****
>
> ** **
>
> Good luck with linking the EBM paradigm with the patient centred paradigm.
> Do let us know how you get on! ****
>
> ** **
>
> Best wishes****
>
> ** **
>
> ** **
>
> Neal****
>
> Professor Neal Maskrey****
>
> Consultant Clinical Adviser, Medicines and Prescribing Centre****
>
> National Institute for Health and Care Excellence
> Ground Floor Building 2000 Vortex Court | Enterprise Way | Wavertree
> Technology Park | Liverpool L13 1FB | United Kingdom****
>
> Tel: +44 (151) 353 7729 | Fax: +44 (151) 220 4334****
>
> Honorary Professor of Evidence-informed Decision Making, Keele University,
> Staffordshire. ST5 5BG.****
>
>
> Web: http://nice.org.uk****
>
> ** **
>
> ** **
>
> ** **
>
> ** **
>
> ** **
>
> *From:* Evidence based health (EBH) [mailto:
> [log in to unmask]] *On Behalf Of *k.hopayian
> *Sent:* 08 May 2013 08:13
> *To:* [log in to unmask]
> *Subject:* Re: EBM and Person-centred care - can you have one without the
> other?****
>
> ** **
>
> Hi Phyll,****
>
> There is the Sicily Statement <http://www.biomedcentral.com/1472-6920/5/1> which
> includes an explicit statement that those receiving care should be the ones
> who make decisions with clinicians seen as a resource of information. That
> puts patients at the centre of care. We debated the use of the term
> patient-centred but dropped it in the end because we were informed that
> (back then) there was not an equivalent in some languages.****
>
> Evidence-Based Practice (EBP) requires that decisions****
>
> about health care are based on the best available, current,****
>
> valid and relevant evidence. These decisions should be****
>
> made by those receiving care, informed by the tacit and****
>
> explicit knowledge of those providing care, within the****
>
> context of available resources.****
>
> What the statement leaves out is HOW.****
>
> ** **
>
> Dr Kev (Kevork) Hopayian, MD FRCGP
> General Practitioner, Leiston, Suffolk
> Hon Sen Lecturer, Norwich Medical School, University of East Anglia
> Primary Care Tutor, East Suffolk****
>
> RCGP Clinical Skills Assessment examiner****
>
> http://www.angliangp.org.uk/****
>
> ** **
>
> On 7 May 2013, at 16:51, Phyll Buchanan <[log in to unmask]>
> wrote:****
>
>
>
> ****
>
> Dear all,
>
> This list has helped me many times, thank you.
>
> I am about to do a presentation and would like some help in thinking this
> through - and I would really like some critical feedback before I do this
> for real.
>
> At a previous research conference we challenged experienced researchers,
> working in the field of person-centred care, to be clear about their
> definitions, in order to help us understand the findings and perhaps
> incorporate them into our work.
>
> My colleague and I are tutors with a voluntary organisation which provides
> breastfeeding support to new mothers, so already feeling a bit overawed
> when our challenge was accepted and  we were invited back to present our
> own thoughts on defining person-centred care. The deadline is getting close
> - about a month away.
>
> Now I know more about evidence-based healthcare I realise they were not
> using reporting techniques familiar to this list. So, if we are to do a
> decent presentation, it means showing this distinguished, but perhaps
> sceptic, audience the relevance of evidence-based healthcare for their work
> as well as explain our understanding of person-centred care.
>
> Taking this challenge further, and having looked at the definitions pasted
> below, I would like to argue that person-centred care is at the centre of
> the EBM definition but EBM is not explicitly within definitions of
> person-centred care.
>
> Is this reasonable?
>
> I would then like to explore methods of testing whether care given is
> perceived by the person at the receiving end as both evidence-based and
> person-centred.
>
>
> I will follow-up the leads given by Hudon ( 2011) on appropriate
> measurement tools but would be very grateful if anyone knew of any existing
> work testing how patients experience EBM care?
>
>
> Definitions
>
> EBM definition (Straus, 2011:1)
> Evidence-based medicine (EBM) requires the integration of the best
> research evidence with our clinical expertise and our patient’s unique
> values and circumstances.
> Values are defined as … unique preferences, concerns and expectations each
> patient brings to a clinical encounter and which must be integrated into
> clinical decisions if they are to serve the patient.
>
> Person centred care
> Duncan seems the closest with the inclusion of effective care.
> “Responsive to individual personal preferences, needs and values and
> assuring that patients values guide all clinical decisions”
> Scottish Government (2010) Healthcare Quality Strategy (cited by Duncan,
> 2011)
>
> ‘Health care services and staff: Have characteristics that equip them to
> deliver consistently good care; act in ways that show they are willing and
> competent to attend to my health and care needs, and respect me as a person
> as they do so; and enable me to be and do what I value being and doing
> within and beyond my health care encounters’. (Entwistle, 2012)
>
> …the patient needs to perceive that his or her individual needs and
> circumstances are at the heart of the clinical care he or she receives…
> (Hudon, 2011)
>
>
> Phyll
>
> My background: I am completing my MSc in Evidence-based Healthcare which
> has transformed my thinking, I was a nurse many years ago, co-founded a
> voluntary organisation 17 years ago and am involved in training women to
> become peer supporters for new mothers.
>
>
> Duncan, E. (2011) Person Centred Care : what is it and how can it be
> improved? : University of Stirling.
>
> Entwistle, V., Firnigl, D., Ryan, M., Francis, J. & Kinghorn, P. (2012)
> Which experiences of health care delivery matter to service users and why?
> A critical interpretive synthesis and conceptual map. J Health Serv Res
> Policy. 17, 70-8.
>
> Hudon, C., Fortin, M., Haggerty, J. L., Lambert, M. & Poitras, M. E.
> (2011) Measuring patients' perceptions of patient-centered care: a
> systematic review of tools for family medicine. Ann Fam Med. 9, 155-64.
>
> Straus, S. E., Glasziou, P., Richardson, S. W. & Haynes, R. B. (2011)
> Evidence-based medicine: how to practice and teach it. London, Churchill
> Livingstone /Elsevier.
>
>
>
> ****
>
> ** **
>
>
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