the key point here (and not only in the setting of medical malpractice) is that decisions are CATEGORICAL (i.e. one decides or not, he/she acts or not act) while the judgments about evidence are expressed in terms of PROBABILITY (uncertainty) language. This simple, but fundamental point has often been neglected in the discussion of evidence-based decision-making.
Benjamin Djulbegovic, MD,PhD
Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute
at the University of South Florida
Department of Interdisciplinary Oncology
SRB #4, Floor 4, Rm #24031 (Rm# West 31)
12902 Magnolia Drive
Tampa, FL 33612
Editor: Cancer Treatment Reviews (Evidence-based Oncology Section)
http://www.harcourt-international.com/journals/ctrv/
e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/
phone:(813)979-7202
fax:(813)979-3071
-----Original Message-----
From: Paul Flynn [mailto:[log in to unmask]]
Sent: Wednesday, November 03, 2004 7:00 PM
To: [log in to unmask]
Subject: Re: Medical malpractice & EBM
Amit, I entirely agree. The application of best evidence, taking into
account the patient's wishes, preferences, etc., means that subjective
judgement will always be a part of medical decision-making and thus open to
challenge, especially when the inevitable bad outcomes occur.
EBM perhaps has a role in helping to shape the expectations of our patients
as over-optimistic expectations are often the root cause of patient
complaints and litigation. Pressurising the mainstream media to use the
principles of EBM in reporting healthcare issues would probably prove a good
investment.
Paul.
On 3/11/04 22:21, "Ghosh, Amit K., M.D." <[log in to unmask]> wrote:
> Paul,
> I agree with your observation.
> We recently reported on the issue of using EBM in moments of uncertainty.
> There are no easy answers. Though knowing when there is inadequate or
> conflicting evidence needs a honest reappraisal and not an unmindful
> application of evidence.
>
> On the challenges of using evidence-based information: the role of clinical
> uncertainty.
> Ghosh AK. J Lab Clin Med. 2004 Aug;144(2):60-4.
>
> The Division of General Internal Medicine, Mayo Clinic College of Medicine,
> Rochester, MN 55905, USA. [log in to unmask]
>
> Evidence-based medicine helps physicians appraise the latest and best evidence
> and incorporate patient's values in reaching a shared clinical decision.
> However, many decisions in medicine are made in the paucity of best evidence.
> Medical uncertainty remains inherent in clinical practice and contributes to
> significant variability in the way physicians and patients manage medical
> problems. Physicians and patients have varying degrees of tolerance for
> uncertainty. Intolerance to uncertainty among physicians results in increased
> test ordering tendencies, variability in medical treatment, failure to comply
> with evidence-based guidelines, and even guide career choices. Factors that
> result in the variability of physicians' interpretation of an effective
> treatment include: patient factors (prioritizing some factors over others),
> physician factors (lack of knowledge, lack of resources, medical uncertainty),
> and environmental factors (limitation of time and practice). Several approach
> es that have been found useful in implementing evidence in clinical practice
> include: sending reminders to prompt physicians to perform patient-related
> clinical activities, introducing computer information systems to support
> practice, and using interactive education interventions to teach newer skills
> and challenge negative attitudes. Passive educational approaches, like
> dissemination of guidelines and didactic lectures, are usually less useful in
> changing behavior. Among the techniques found to be useful for managing
> uncertainty are shared decision making, meticulous history taking, and
> physical examination, excluding worrisome differential diagnosis and
> establishing trust in patients. The role of future studies in assessing the
> outcome of multiple evidence-based strategies in situations of medical
> uncertainty remains to be explored.
>
> Amit K. Ghosh, MD, FACP
> Consultant, Internal Medicine
> Mayo Clinic College of Medicine , Rochester
> Phone:507-538-1128
> Fax: 507-284-4959
>
>
>> -----Original Message-----
>> From: Evidence based health (EBH)
[SMTP:[log in to unmask]]
>> On Behalf Of Paul Flynn
>> Sent: Wednesday, November 03, 2004 3:30 PM
>> To: [log in to unmask]
>> Subject: Re: Medical malpractice & EBM
>>
>> I think that EBM may be a bit of a false dawn in the realm of medical
>> malpractice/negligence. Firstly there are so many gaps in the evidence
>> available to doctors that they will always have to use their own judgement.
>>
>> Secondly, although there may be evidence regarding management of a
>> situation, the diagnosis may rely on subjective interpretation e.g.
>> Diagnosis of fetal acidosis in labour with CTG. In my experience of Risk
>> Management in Obstetrics, knowledge of criteria for interpretation of CTGs
>> is not synonymous with correct interpretation and appropriate action.
>>
>> I do think that the sooner we move away from the situation where courts rely
>> on partisan 'experts' and use professional bodies who create evidence-based
>> guidelines.
>>
>> Paul.
>>
>> --
>> Mr Paul M Flynn MRCOG
>> Clinical Director Obstetrics & Gynaecology, Swansea NHS Trust
>> +44 1792 285687 Fax: +44 1792 285874
>>
>>
>> On 3/11/04 19:42, "Dean Giustini" <[log in to unmask]> wrote:
>>
>>> Here's a question posed today: is one answer to the complex issue of>
>>> rising medical malpractice in Canada, the United States and the UK,>
>>> broader and more meaningful adoption of the principles of EBM?
>>>
>>> Of course, finding the evidence is a critical part of the practice of
>>> EBM. However, complete and flawless evidence is not enough to make valid
>>> and valuable treatment choices.
>>>
>>> If the interpretation of the evidence is not logically sound or if it is
>>> used uncritically, a patient could be harmed. Harm might also occur by a
>>> logically flawless use of poor or poorly evaluated evidence.
>>>
>>> Thank you for your responses to me, offline.
>>>
>>> Dean Giustini, Branch Librarian
>>> University of British Columbia
>>> Biomedical Branch Library
>>> Vancouver General Hospital - Heather Pavilion
>>> Vancouver Canada
>>> (604) 875-4505
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