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Hi Ben, Rakesh, These are the typical differences between novice and expert learners and the brain areas that are activated as a result. Above all physicians are people why not look to neuroscience Best Amy From: "Djulbegovic, Benjamin" <[log in to unmask]> Reply-To: "Djulbegovic, Benjamin" <[log in to unmask]> Date: Friday, July 4, 2014 at 7:55 AM To: <[log in to unmask]> Subject: Re: RealEBM paper Very nice, Rakesh The problem is that we still know so little about the ways physicians think. In the recent paper on evaluation of physicians' cognitive styles (http://www.ncbi.nlm.nih.gov/pubmed/24722474), we found that trainees showed a tendency to engage in analytical thinking, while attendings (older, more experienced physicians) displayed inclination toward intuitive-experiential thinking. The trainees, however, performed worse on conditional inference task. The findings again raise the issue of nature of medical knowledge with a number of implications for teaching ( of EBM). Best Ben Sent from my iPad ( please excuse typos & brevity) On Jul 3, 2014, at 11:14 PM, "Rakesh Biswas" <[log in to unmask]> wrote: > Thanks Huw for this excellent description of what may constitute an 'ideal > evidence based patient encounter.' > > To further attempt to expand on it, perhaps after the initial encounter and > listening carefully to symptoms, wishes and views, asking questions, examining > and doing tests driven by 'intuitive' 'system 1' processing, healthcare can > tremendously benefit from a workflow where this is routinely followed by an IT > enabled system 2 processing. A workflow that for each patient may routinely > include: > > a) Searching for current best evidence for diagnosis and further management of > the 'particular patient's' described condition. > > followed by > > b) Matching the available 'particular patient' data to generalizable patient > data/current best evidence available online > > and finally > > c) Coming up with a contextually matched patient management plan for shared > decision making. > > I guess the above is 'old hat' theoretically but implementation leaves a lot > more to be desired (not that we aren't trying). :-) > > Here's some more literature :http://www.biomedcentral.com/1472-6947/4/19 on > 'particular patient' based reasoning if one would have the stomach for it (one > relatively easier way to grasp this article is to just click on the figures > and go through them). > > best, > > rakesh > > > On Wed, Jul 2, 2014 at 4:37 PM, Huw Llewelyn [hul2] <[log in to unmask]> wrote: >> I agree with everyone that compassion and sensitivity to a patient¹s wishes >> is central to medical practice and that Neal¹s account of his late mother¹s >> illness typifies this. However, I would like to draw attention to another >> neglected aspect of EBM. I think that ŒReal EBM¹ also involves: >> 1. listening carefully to symptoms, wishes and views, asking questions, >> examining and doing tests guided partly by diagnostic hypotheses and partly >> by checklists, all driven by 'intuitive' 'system 1' thought based on an >> amalgam of personality, personal experience, didactic and problem-based >> learning, imagination from medical theories, observational studies, RCTs, >> meta-analyses and guidelines from diverse sources such as NICE, etc. >> >> 2. suggesting diagnoses and justifying each one with the relevant >> Œpatient¹s evidence¹ in the form of the Œrelevant¹ symptoms, physical signs >> and test results from (1) >> >> 3. suggesting treatments and further tests also with further justifying >> Œpatient¹s evidence¹ from (1) that include the patient¹s wishes and desires >> >> The Œpatient¹s evidence¹ referred to above is the Œparticular¹ evidence based >> on Œparticular propositions¹ or Œfacts¹ obtained from the Œparticular¹ >> patient in terms of symptoms, views and feelings, physical signs and test >> results (as opposed to Œgeneral evidence¹ based on Œgeneral propositions¹ >> based on research observations on groups of patients). This Œpatient¹s >> evidence¹ has not been part of Œtraditional¹ EBM. If it is written alongside >> a diagnosis or decision as taught in the Oxford Handbook of Clinical >> Diagnosis, the Œparticular evidence¹ helps others to understand one¹s >> reasoning. It also allows a diagnosis and decision based on this Œparticular >> evidence¹ to be checked against published guidelines. Finding such a >> published guideline that arrives at the same diagnosis and decision based on >> similar findings and based (to some degree or other) on research evidence >> that supports a diagnosis or decision might be regarded as Œvalidating¹ it >> e.g. in accordance with the Bolam test in British Tort Law if the authors >> (e.g. a NICE committee) can be regarded as a reasonable body of opinion! (see >> also my post on the 19th May beginning "Dear Rakesh and everyone".) >> With best wishes >> Huw >> Dr Huw Llewelyn MD FRCP >> Aberystwyth University >> >> From: Evidence based health (EBH) [[log in to unmask]] on >> behalf of healingjia Price [[log in to unmask]] >> Sent: 02 July 2014 06:32 >> >> To: [log in to unmask] >> Subject: Re: RealEBM paper >> >> Hi Rinku, >> >> This was a title for a paper Neal Maskrey is working on writing. The other >> is my response as the concept resonated deeply in me. To me choosing kindness >> and to remain kind in adversity is greatness and something I work to grow >> better at, I believe there is healing in kindness and power in gentleness >> that is chosen. >> Best >> Amy >> >> Amy Price >> Empower 2 Go >> Building Brain Potential >> Http://empower2go.org >> Sent from my iPad >> >> On 2 Jul 2014, at 01:11 am, "Rinku Sengupta" <[log in to unmask]> wrote: >> >>> Hi Amy >>> ''Small is beautiful'' - please send in the whole link-seems like something >>> to look into 'deeply'-a very intersting choice of words below-especially- >>> the ability to be/remain kind amongst adverse conditions-evidence based or >>> not. >>> Thanks >>> Rinku >>> Dr Rinku Sengupta >>> MBBS DGO MRCOG PGCERT MED ED >>> MEDICAL OFFICER(voluntary) >>> Dept Of Obstetrics and Gynaecology >>> Matri Bhavan Hospital >>> Kolkata >>> India >>> 00 913324174046 >>> >>> >>> On Wednesday, 2 July 2014, 2:03, Amy Price <[log in to unmask]> wrote: >>> >>> >>>> ³Small is beautiful: a study of evidence-based medicine as if people >>>> mattered² (Copyright reserved!).NM I love this concept, kindness, asking >>>> questions that matter and being fully present are choices that are within >>>> our power to make. I would add that helplessness is something clinicians >>>> face often and it is the most difficult of all as it can kidnap strength >>>> and empathy making it important to remember self kindness and compassion >>>> as well so there is space to give to others who have misplaced hope and >>>> strength. Thank you all for being a wonderful, diverse and kind strength >>>> giving group. >>>> >>>> Best >>>> Amy >>> >>> From: "Djulbegovic, Benjamin" <[log in to unmask]> >>> Reply-To: "Djulbegovic, Benjamin" <[log in to unmask]> >>> Date: Tuesday, July 1, 2014 at 7:40 PM >>> To: <[log in to unmask]> >>> Subject: Re: RealEBM paper >>> >>> Neal, >>> It is so satisfying that your mom had a long, meaningful and fulfilling life >>> surrounded by her family who has supported her to live consistently with her >>> outlook at the world...but, as you so eloquently analyzed it, her medical >>> management was completely consistent with the precepts of EBM...no doubt >>> there will never be "idiot-proof" guidelines, and as saying goes " a good >>> doctor knows how to treat, better one when to treat/order dx test, and best >>> one when NOT to administer Rx/order test"...but your and your colleagues >>> piece is ultimately about the nature of medical knowledge and expertise ( in >>> the context of more humane and compassionate care)... >>> EBM has started its revolution by challenging knowledge of >>> experts....telling us that we should never stop asking a question "how do >>> experts know?" But, more often than not we- particularly trainees- continue >>> to invoke authority in answering questions asked about patient management. >>> Thanks for opening this interesting tread >>> Ben >>> >>> Sent from my iPad >>> ( please excuse typos & brevity) >>> >>> On Jul 1, 2014, at 3:40 PM, "Neal Maskrey" <[log in to unmask]> wrote: >>> >>>> Well, thanks Ben and everybody. Most encouraging. >>>> >>>> Just to interject a note of caution, when faced with an 84 year old woman >>>> with new atrial fibrillation after a recent myocardial infarction, an >>>> unexplained recent episode of iron deficiency anaemia (too ill post MI to >>>> investigate), a recent stroke (full recovery in 3 days), long standing >>>> osteoporosis, impaired renal function and long standing heart failure >>>> controlled with an ACEiŠŠŠŠŠhow does evidence in the form of rules, >>>> guidelines, technology assessment or anything else help us? >>>> >>>> We know (or could find out) what the data look like for most of the >>>> treatments we¹d consider for most of these conditions individually but >>>> there were few people in the RCTs aged 84, never mind one of those >>>> co-morbidities and certainly not all of them. We have no idea from the >>>> evidence what is the best treatment for those conditions in combination. >>>> The research data might or might not be deliberately flawed, but really in >>>> such circumstances it¹s only a guide at best. >>>> >>>> Whether its rules or evidence, we are indebted to and need to rely to two >>>> things. The expertise of the clinician who has seen some people with some >>>> of these diseases in combination and has that experience and expertise to >>>> offer. And, even more importantly, the values and preferences of the >>>> patient (see the RealEBM paper for the principles). >>>> >>>> In this particular case, the patient was not the slightest bit interested >>>> in the AF and stroke prevention, one of the medical imperatives. She >>>> dismissed the offer of AF decision aids. Her agenda was she felt lousy most >>>> days, she needed kindness and help with daily living, she wanted her >>>> medicines reviewed so she didn¹t have to take any medicines other than >>>> those which kept her symptoms down, and she definitely didn¹t want warfarin >>>> (even if someone was willing to give it to her) because her husband had >>>> been on that and it was awful trying to get INR control and there was no >>>> way she could get to the clinic to have her blood taken anyway because her >>>> son would have to take her and she didn¹t want to be any more of a burden. >>>> >>>> The above is a real patient. She recovered pretty well and lived almost >>>> independently with no further acute serious illness in what she called her >>>> luxury penthouse apartment on many fewer medicines, loved and cared for by >>>> her large extended family, and definitely taking nothing for her stroke >>>> prevention for 4 years, dying peacefully 2 months short of her 89th >>>> birthday. She happened to be my Mum. >>>> >>>> The genius of Sackett, Guyatt et all still shines through. >>>> Clinical expertise, needs and wishes of the patient, explicit use of >>>> evidence (definitely not rules). All focussed on the best care for >>>> individuals. No matter what ³the rules² say. >>>> Andy Hutchinson reminded me today about EF Schumacher and his 1973 book >>>> ³Small is Beautiful: a study of economics as if people mattered². We >>>> laughed and said we need ³Small is beautiful: a study of evidence-based >>>> medicine as if people mattered² (Copyright reserved!). >>>> >>>> Nothing has changed since the BMJ in 1996. Just that we need more than the >>>> industrial scale production of guidelines, protocols and SOPs, all of which >>>> which are necessary but which are not sufficient for the present, never >>>> mind the future. >>>> >>>> And at the risk of being accused of self-publicity see >>>> http://blogs.bmj.com/bmj/2014/07/01/neal-maskrey-the-importance-of-kindness>>>> / >>>> >>>> Best to all >>>> >>>> >>>> Neal >>>> Professor Neal Maskrey >>>> Consultant Clinical Adviser, Medicines and Prescribing Centre >>>> National Institute for Health and Care Excellence >>>> Level 1A | City Tower | Piccadilly Plaza | Manchester M1 4BT | United >>>> Kingdom >>>> Tel: 07770535128 >>>> Visiting Professor of Evidence-informed decision making, Keele University, >>>> Staffordshire. ST5 5BG >>>> >>>> >>>> >>>> From: Djulbegovic, Benjamin [mailto:[log in to unmask]] >>>> Sent: 01 July 2014 16:35 >>>> To: Neal Maskrey; [log in to unmask] >>>> Subject: RE: RealEBM paper >>>> >>>> >>>> Well done Neal and colleagues. Nothing to disagree with. However, I found >>>> the following sentence a key to the possibility of resolving the dilemmas >>>> identified in your paper (³Evidence based medicine: a movement in crisis?²) >>>> >>>> ³Given that real evidence based medicine is as much about when to ignore or >>>> over-ride guidelines as how to follow them, those who write guidelines >>>> should flag up the need for judgment and informed, shared decision making.² >>>> >>>> This really bring us back to the seminal 1992 JAMA paper, which introduced >>>> EBM and highlighted the role of experts (and nature of expertise); should >>>> we trust experts with their tacit knowledge based on private evidence not >>>> accessible to others, or should we insist on explicit, public type of >>>> knowledge that can be understood by all people who share a common set of >>>> the tools (and values)? The public scrutiny and demand for accountability >>>> currently heavily favors ³rules² over ³judgments² Š. I am skeptical that we >>>> will see fundamental changes any time soon even if successfully enact all >>>> initiatives outlined in Box 3 of the paperŠ >>>> This, of course, is not to say that we should not try, but as they say ³it >>>> is complicated²J >>>> Best >>>> ben >>>> >>>> >>>> From: Evidence based health (EBH) >>>> [mailto:[log in to unmask]] On Behalf Of Neal Maskrey >>>> Sent: Friday, June 13, 2014 2:16 PM >>>> To: [log in to unmask] >>>> Subject: RealEBM paper >>>> >>>> http://www.bmj.com/content/348/bmj.g3725 >>>> >>>> Trish is up a mountain so I¹ll post that this is published online in the >>>> BMJ today. >>>> >>>> The amazing Trish G who led all this magnificently, lots of big >>>> brainsŠŠŠ.and little me. >>>> >>>> The BMJ seems to have website problems today; I can only get this via >>>> Explorer and not on the iPad (yet?). Be gentle dear friends, be gentle. >>>> >>>> And of course, thanks as ever for all the stimulationŠŠŠŠ >>>> >>>> Best to all >>>> >>>> Neal >>>> Professor Neal Maskrey >>>> Consultant Clinical Adviser, Medicines and Prescribing Centre >>>> National Institute for Health and Care Excellence >>>> Level 1A | City Tower | Piccadilly Plaza | Manchester M1 4BT | United >>>> Kingdom >>>> Tel: 07770535128 >>>> Visiting Professor of Evidence-informed decision making, Keele University, >>>> Staffordshire. ST5 5BG >>>> >>>> >>>> The information contained in this message and any attachments is intended >>>> for the addressee(s) only. If you are not the addressee, you may not >>>> disclose, reproduce or distribute this message. 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