What has been missing in this discussion is explicit consideration of TIME factor. If we have all time (and resources) in the world available to us, then arguably any of us could come up with the advice which is in the best interest of patients. The problem is, as the folks of this discussion group know it too well, that we have to give our advices and make decisions in the framework of LIMITED TIME (fraught with uncertainties and lack of reliable information). As two Nobel laureates (Simon and Kahneman) showed, under circumstances such as a typical clinical encounter we have to act (and interact) within a framework of "bounded rationality", to use "satisficing" rather than "maximizing" strategy. The challenge is to identify these "boundedly rational rules of thumb" that can be easily transportable to different setting (and are still associated with attributes of a "good" decision).
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, MRC, Floor 2,Rm# 2067H
12902 Magnolia Drive
Tampa, FL 33612
e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/
phone:(813)972-4673
fax:(813)745-6525
-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Jim Freeman
Sent: Monday, August 14, 2006 11:14
To: [log in to unmask]
Subject: Re: Commentary About EBM from Peru
A fine new book, edited by Heritage and Maynard, uses the framework of conversation analysis to deconstruct the ambulatory medical encounter.
--
This is a very interesting thread. There has been much important research examining different elements of patient-clinician communication, but I feel that we are still missing a unified understanding of the process; we are learning more and more, but are having trouble applying our knowledge effectively.
Jim
The book:
John Heritage and Douglas W. Maynard, Eds (2006). Communication in Medical
Care: interaction between primary care physicians and patients. Cambridge,
UK: Cambridge U Press.
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Harris, Janet
Sent: Monday, August 14, 2006 8:25 AM
To: [log in to unmask]
Subject: Commentary About EBM from Peru
Here's a great book on communicating with patients who need to receive information in different ways
Doak, C.C., Doak, L.G. & Root, J.H. (1996) Teaching Patients With Low Literacy Skills. Philadelphia, PA.: J.B. Lippincott.
Janet Harris
Academic Director, Health Sciences
Continuing Professional Development Centre University of Oxford www.conted.ox.ac.uk/health
-----Original Message-----
From: Evidence based health (EBH)
To: [log in to unmask]
Sent: 13/08/2006 22:12
Subject: Re: Communicating with patients when time is short
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
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