I agree whole heartedly with the threads of this discussion. The
technical aspects involved in EBM are difficult enough. Incorporating
EBM into real-world decision making jointly with patients on a fuly
informed basis seems to me to be still, if not in its infancy, barely
into a baby walker.
Two nmemonics, no doubt familiar to UK GPs preparing for Membership of
the Royal College of General Practitioners.
Are these helpful / well known?
1. (Usually fairly early in the consultation).
ICE (Seeking information)
I Ideas e.g. "What do you think might be causing
this?" - obviously looking for the patients perspective, and important
in itself but sometimes vital in arriving at
the right diagnosis. I saw a video consultation recently with a patient
with a cough. Without asking the
question the doctor moves right into the antibiotics / no antibiotics
debate. However, when the above question was
asked, the following was the response "Well, I work with asylum seekers
and quite a few of them have TB....and I have been having
these dreadful night sweats....".
C Concerns Often just an open question. e.g. "This
must have been worrying you" followed by some silence. Can sometimes
elicit remarkable insights into some
agendas that otherwise we'd have no idea were present. E.g. "If this is
something serious then I've a child with
E Expectations This moves more into Paul's territory, but not
quite because this not about giving information. Before that occurs,
this it is an attempt to uncover what the
patient thinks we can do. E.g. "What do you know about this? What do you
know about how this is treateed these
I apologise for the trite phrases. Everyone can find their own that work
2. (Usually towards the end of the consultation).
OICJ (Giving information)
O Options "We could do X or Y or Z"
I Implications "If we do X (and this could be nothing as in
Paul's model), then its likely that...... On the other hand if we do
C Choice "On balance, I'd usually choose Y". Often
precedded by an interim step when the patient is asked what they think
about those choices.
J Justification Sometimes not required, but if it is.... E.g.
"Here's a picture that explains the limited benefits of antibiotics in
middle ear infections. It shows, a hundred
children who have ear inections, and - to the best of our knowledge -
what happenns to them without
antibiotics. Let me take you through this...." ...."And here's another
picture which explains the benefits of
antibiotics.....and finally here's a third picture which shows how many
extra children are made ill by side effects from
antibiotics. What do you think is the best we can do here?".
The skills required here are, as yet, still in development. But we could
perhaps envisage the norm being clinicians being able to understand a
summary of evidence from a trusted source. I agree that for the majority
critical appraisal is mostly about understanding what someone else has
done, because (assuming you've done it really well), if you read and
critically appraised a recent paper all you've done is read that paper.
What if there are another six in the literature that say we should treat
patients in an entirely different way? If the clinician can understand
the summary, then there's usually a need to turn those results from
absolute to relative and then into "If we were to think of a hundred
people like you, then xx will be ok over the next 5 years with no
treatment. However, that means yy will have...." As a skill, consulation
translation "from evidence to meaningful information for patients" is
really not there at the moment - at least based on my experiences in the
Feedback would be much appreciated.
Neal Maskrey. Medical Director, National Prescribing Centre, 70 Pembroke
Place, Liverpool L69 3GF. Tel: 0151 794 8135. e-mail:
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