Thanks Amit, for having brought out the relevant issues. Resolving
uncertainty is perhaps our daily bread and the tools we use are often
surprisingly
simple. We did a study with our medical students in the role of fever charts
to resolve diagnostic uncertainty in intitially poorly localizable fevers
that may have helped prevent a lot of antbiotic misuse in the third world.
We found
most of our problems could be solved if one judiciously used fever charts
only for the first few days of fever in the community. However the next
important step would be how to validate this not too complex intervention?
Even if it gets published in a medline indexed journal(Biswas R,Dhakal B et
al Resolving diagnostic uncertainty in initially poorly localizable fevers,
IJCP, Jan 2004, vol 58/1), how does one really figure out if fever charts
really work to that extent. The answer is possibly peer review and then
other studies repeating it and actually testing it out in the community
which might involve a lot of health assistant training. Both patients and
health assistants need training to use that simple tool... the complexity
lies in making the end user take to it. That brings us to "Diffusion of
innovation" a theme that's prety much doing the rounds in complexity lists
these days.Rakesh
----- Original Message -----
From: "Ghosh, Amit K., M.D." <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, February 26, 2004 6:24 AM
Subject: Re: evaluating complex interventions
> > Dear Paul,
> >
> > I have struggled with this issue and the reality of the fact is that
there is uncertainty in several of our clinical decision making process in
General Medicine. The compliance to guideline remains suboptimal and the
preparations of guidelines are based on evidence in less than 50% of cases.
> >
> > Physicians have their own tolerance to uncertainty. Martha Gerrity's
from Oregon, currently editor of JGIM) Physicians response to uncertainty
scale has identified that orthopedic's and Urologist have the lowest
tolerance to uncertainty, while Psychiatrist and family physicians have the
highest tolerance to uncertainty.
> >
> > Ralph Stacey's( UK) classical certainty/ agreement diagram ( high
agreement, high certainty- simple case versus low agreement, low certainty
resulting in chaos) demonstrates why in a complex adaptive case physicians
and patients differ in their perception of the problem.
> > Alternatively varying degree of adherence to the 6 steps of informed
decision making process( Debra Roter's work) with minimal time being spent
on discussing the uncertainty around a decision make most decision making
process far from adequate.
> >
> > The question of patients and physicians risk aversion has also been
considered in recent literature and makes interesting reading. In fact they
have over 8 scales to measure uncertainty in medical students and physician
( Budner''s scale, Gerrity scale etc.) and medical students can be
identified quite early as to their future selection of specialty. Though in
US student debt load (> $ 100,000 on average ) has to be factored into the
process of career selection ( economics over everything).
> >
> > I routinely give a talk on how to measure and deal with physician
uncertainty, in an effort to teach resident and fellows how to develop
techniques to deal with complex., and uncertain diagnosis where EBM falls
short for e.g., by using tacit reasoning, improving communication, using
formal decision analysis (here they fall asleep or leave). I however get the
feeling that the disease oriented approach that we preach to our students
and often believe ourselves) and the method of selection of students on the
basis of objective testing and not an overall perusal of their abilities for
rationalist reasoning and consideration of medicine as truly being a patient
focussed discipline, makes General Medicine currently a threatened
specialty. Many students find this complex reasoning process , 1) not
uniformly stressed in medical school, 2) sub-specialize and be very
comfortable with a series of high agreement, high certainty procedures.
> >
> > I would be happy to provide references on uncertainty on any of our
members . A medline search using terms such risk aversion, physicians
response to uncertainty scale, articles by Trish Greenhalgh in BMJ on
Complexity Science would provide you will more than ample material in this
field
> >
> > Amit K. Ghosh, MD, FACP
> > Associate Program Director, General Internal Medicine Research
Fellowship
> > Consultant
> > Division of General Internal Medicine
> > Assistant Professor of Medicine
> > Mayo Clinic College of Medicine
> > 200 1st Street, SW
> > Rochester, MN, 55905
> > Phone: 507-538-1128
> > Fax: 507-284-4959
> > [log in to unmask]
> >
> >
> > -----Original Message-----
> > From: Evidence based health (EBH)
[SMTP:[log in to unmask]] On Behalf Of Paul Glasziou
> > Sent: Thursday, February 26, 2004 3:15 AM
> > To: [log in to unmask]
> > Subject: evaluating complex interventions
> >
> > Dear All,
> > One of the tricky issues in EBM is the evaluation of complex
interventions,
> > such as quality circles or critical appraisal training.
> > Do you think RCTs should always be the gold standard for
evaluating highly
> > complex social interventions?
> > I'd encourage you to look at:
> > http://bmj.bmjjournals.com/cgi/content/full/328/7434/282>
> > and have your say in the rapid response,
> >
> > Paul Glasziou
> > Department of Primary Health Care &
> > Director, Centre for Evidence-Based Practice, Oxford
> > ph: 44-1865-227055 www.cebm.net
>
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