Dear All,
Re communicating with patients:
We advocate a slightly different approach. We agree completely with Paul's
point about providing information about the “if we do nothing” followed by a
listing of options and benefits/risks of each. However, we use a model for
decision-making based on both the strength of the evidence and a
decision-making process that shifts from physician-directed to shared
decision-making to patient-directed decision-making depending upon the
situation.
Example1: A healthy patient with URI and who now has developed a cough and
is requesting antibiotics:
* Since there is sufficient evidence to conclude that antibiotics do
not provide clinically meaningful benefits and carry risk of harms (GI sxs,
vaginitis, etc.) we will start out with a fairly directive approach—“You
have a viral cough and it will run its course within days to several weeks.
Here are some things you can try--antibiotics are not helpful and carry the
risk of causing more harm than good…” This is a physician-directed
beginning because of the evidence.
* If the patient says, “Antibiotics always work for me,” we would try
to explain the natural history and stick with our initial approach.
* If the patient continues with a patient-directed approach (strongly
wishing antibiotics) we will then shift to his/her decision-making
preference and treatment preference and carefully document our discussion in
the chart. We would still urge caution and although providing the
prescription, suggest the patient wait for another several days to see if
he/she improved without the antibiotics.
Example 2: A 60 year old man inquires about screening for prostate cancer.
* Since the evidence for screening and treatment is not strong, we
would start with a balanced approach laying out the lack of evidence for
benefit, the known harms of treatments and moving quickly to the patient’s
values and preferences.
Michael Stuart MD
Sheri Strite
Delfini Group LLC
www.delfini.org
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Paul Glasziou
Sent: Sunday, August 13, 2006 8:36 AM
To: [log in to unmask]
Subject: Re: Commentary About EBM from Peru.
Dear All,
Very interesting comments - the two-way communication is difficult when
we are short of time and words mean different things to different folk.
I don't think there is any easy way out for EBMers or non-EBMers.
But a process we suggested in the book "Clinical Thinking" recently was
to use the following three steps:
1. What would happen if we did nothing?
We may begin explaining the disease by saying something like: “Do you
know about X? OK, well let me explain. If we did nothing the usual
course of the illness is to …”
2. Explain what the options there are:
We next list and explain the main management options, for example:
“There are three common things we can do about this: a pill, or surgery,
or we can let it take its course (natural history)”.
3. Check the patients expectations and ideas:
We should know if the patient has tried any of the options, or has prior
knowledge and expectations about them. For example, “Have you tried
anything yourself, or did you have a preference for one of those
options?” At this point a dialogue may ensue about the pros and cons of
the various options, or the patient may simply ask what you recommend.
I pretty much follow this approach in my own clinical practice, but I'd
be interested to know of other approaches to this difficult step,
Paul Glasziou
Bill Cayley, Jr wrote:
> I would agree that the patient preference piece is
> HARD to sort out. And, it's easy enough to list
> illiteracy, differing values, different language (and
> perhaps other issues) as parts of the barrier to
> understanding patiet preference. BUT, in each real
> life, case-by-case situation, how easy is it really to
> understand which (ones) of these are operative.
>
> In clinical practice, how often to we have the time
> and patience to fully sort out whether someone's lack
> of understanding is due to language or intelligence or
> comprehension? Or how about sorting out whether a
> patient's seemingly poor choice is due to different
> values from mine, or a communication barrier, or lack
> of information or lack of intelligence?
>
> There is quite a body of literature out there on
> "reflective" practice, and I think there could be some
> fertile ground for studying how insights from that
> work can inform the clinical practice of EBM.
>
> Bill Cayley MD
>
> --- Diana Rodríguez Hurtado <[log in to unmask]>
> wrote:
>
>
>> Dear Colleagues:
>> About EBM, I am defender of EBM, but in the topic
>> about Patient values and preferences in order to
>> involve the patients in the decision making process,
>> I have a commentary :
>> Don´t you think that sometimes you can find barriers
>> for example in developing countries? Example, when
>> you are in front a patient who is analphabet or that
>> belong to ethnic group whose lexicon we don´t know,
>> with the risk that the patient take an erroneous
>> decision by ignorance.
>> Some day I had listened:
>> "A man who is not informed, he can not have opinion,
>> and a man who has not opinion, he can not take
>> decision" .
>> I would like to receive your answers.
>> Sincerely.
>>
>> Diana Rodriguez M.D.
>> Associate Professor Faculty of Medicine "Universidad
>> Peruana Cayetano Heredia".
>> Master in Clinical Epidemiology.
>> Member of INCLEN (International Clinical
>> Epidemiology Network).
>> Lima , PERU.
>> e-mail [log in to unmask]
>>
>> [log in to unmask]
>>
>>
>>
>
>
> Bill Cayley, Jr, MD MDiv [log in to unmask]
>
> Augusta Family Medicine Home Address
> 207 W Lincoln 3433 McIvor St
> Augusta, WI 54722 Eau Claire, WI 54701
> Work: 715-286-2270 Home: 715-830-0932
> Page: 715-838-7940 Cell: 715-828-4636
>
>
--
Paul Glasziou
Director, Centre for Evidence-Based Medicine,
Department of Primary Health Care,
University of Oxford www.cebm.net
ph +44-1865-227055 fax +44-1865-227036
|