best,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 byI guess the above is 'old hat' theoretically but implementation leaves a lot more to be desired (not that we aren't trying). :-)
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.
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).
rakeshOn 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 patient’s wishes is central to medical practice and that Neal’s account of his late mother’s illness typifies this. However, I would like to draw attention to another neglected aspect of EBM. I think that ‘Real EBM’ 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 ‘patient’s evidence’ in the form of the ‘relevant’ symptoms, physical signs and test results from (1)
3. suggesting treatments and further tests also with further justifying ‘patient’s evidence’ from (1) that include the patient’s wishes and desires
The ‘patient’s evidence’ referred to above is the ‘particular’ evidence based on ‘particular propositions’ or ‘facts’ obtained from the ‘particular’ patient in terms of symptoms, views and feelings, physical signs and test results (as opposed to ‘general evidence’ based on ‘general propositions’ based on research observations on groups of patients). This ‘patient’s evidence’ has not been part of ‘traditional’ EBM. If it is written alongside a diagnosis or decision as taught in the Oxford Handbook of Clinical Diagnosis, the ‘particular evidence’ helps others to understand one’s reasoning. It also allows a diagnosis and decision based on this ‘particular evidence’ 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 ‘validating’ 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 06:32Hi 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.BestAmy
Amy PriceHi 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.ThanksRinkuDr Rinku Sengupta
MBBS DGO MRCOG PGCERT MED ED
MEDICAL OFFICER(voluntary)
Dept Of Obstetrics and Gynaecology
Matri Bhavan Hospital
Kolkata
India
00 913324174046“Small is beautiful: a study of evidence-based medicine as if people mattered” (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.BestAmyFrom: "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 paperNeal,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 treadBen
Sent from my iPad( please excuse typos & brevity)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 ACEi……………how 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 we’d 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 it’s 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 didn’t have to take any medicines other than those which kept her symptoms down, and she definitely didn’t 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 didn’t 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 “the rules” say.Andy Hutchinson reminded me today about EF Schumacher and his 1973 book “Small is Beautiful: a study of economics as if people mattered”. We laughed and said we need “Small is beautiful: a study of evidence-based medicine as if people mattered” (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 allNealProfessor Neal MaskreyConsultant Clinical Adviser, Medicines and Prescribing CentreNational Institute for Health and Care Excellence
Level 1A | City Tower | Piccadilly Plaza | Manchester M1 4BT | United Kingdom
Tel: 07770535128Visiting Professor of Evidence-informed decision making, Keele University, Staffordshire. ST5 5BGFrom: Djulbegovic, Benjamin [mailto:[log in to unmask]]
Sent: 01 July 2014 16:35
To: Neal Maskrey; [log in to unmask]
Subject: RE: RealEBM paperWell 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 (“Evidence based medicine: a movement in crisis?”)“Given 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.”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 “rules” over “judgments” …. I am skeptical that we will see fundamental changes any time soon even if successfully enact all initiatives outlined in Box 3 of the paper…This, of course, is not to say that we should not try, but as they say “it is complicated”JBestbenFrom: 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 paperTrish is up a mountain so I’ll post that this is published online in the BMJ today.The amazing Trish G who led all this magnificently, lots of big brains……….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 stimulation…………Best to allNealProfessor Neal MaskreyConsultant Clinical Adviser, Medicines and Prescribing CentreNational Institute for Health and Care Excellence
Level 1A | City Tower | Piccadilly Plaza | Manchester M1 4BT | United Kingdom
Tel: 07770535128Visiting Professor of Evidence-informed decision making, Keele University, Staffordshire. ST5 5BG
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