Dear all,
Thank you for thinking this through with me.
The diversity in responses shows how difficult it is to grasp the diversity of EBM in everyday clinical practice, but I think we really need to. If we grasp and gain understanding in this diversity, it might help us to develop tailor-made strategies for doctors to progress EBM.
For example, a doctor who has learned to integrate EBM since medical school has incorporated EBM into his/her patterns for clinical decision making. In contrast, a doctor who heard of EBM for the first time while already practicing as a medical specialist or GP has built totally different patterns. I think this will greately influence how these doctors view and (do not) use EBM. For the latter group, I can imagine it must feel like saying to a master chess player that the rules of the game have been changed...
I think we need to define what EBM means in routine clinical practice: in other words, how to balance clinical expertise and evidence...
Today, I will take all your responses with me to London, where I will attend a research meeting 'Making decisions better', organized by the National Prescribing Centre. To be continued...
Kind regards, Maartje Swennen
________________________________
Van: Evidence based health (EBH) namens Maskrey Neal
Verzonden: vr 12-3-2010 23:29
Aan: [log in to unmask]
Onderwerp: Re: What does EBM behaviour look like in real life clinical practice?
I agree Ash. We have to look very critically indeed.
Read the 2006 YouGov survey of medical misdiagnosis at www.isabel-healthcare.com. I presume its still available. This survey of 2201 adults in the US found 35percent had experienced a medical mistake involving their friends family or themselves, and of those about a third resulted in permanent harm or death. If true, that's truly alarming.
Two years ago two consultant cardiologists failed to manage my 85y.o. mother's atrial fibrillation. She'd got all sorts going on and was very sick, but digoxin to control the ventricular rate (which she didn't get for 6 weeks despite my increasingly desperate pleas) isn't exactly that cutting edge. When she did get it, it was truly miraculous. But then I'd never actually seen someone who needed digoxin wait 6 weeks before they got it.
Last month my grown up known-asthmatic daughter got antibiotics and only antibiotics from her GP for quite a nasty asthma exacerbation. It was 1997 when we got British guidelines which set out to improve asthma care and stop just that happening. A few days later she subsequently spent just the 4hours in the local hospital when she got even worse having blood gases etc done, and then she got the course of oral steroids. Three days after finishing that course, her GP stepped her inhaled steroid down. She got worse, now has a different GP practice, is finally now getting guideline-based care but has not been at work for 4 weeks.
Better is possible. It does not take genius, it takes diligence, it takes a clarity of purpose, it takes ingenuity, it takes a willingness to try. (Atul Gawande).
EBM is an essential building block for quality but is insufficient in itself to achieve quality. As I've written before, the data indicates that creating links explicitly in undergrad and postgrad curricula between evidence and clinical decision making might be logical.
But in the meantime Don Berwick has it right. We're occasionally technologically amazing now in medicine, but we've lost track of the basics and we're failing people. Badly. How to bridge that gap takes more than medline searching and critical appraisal skills.
Big questions Maartje.
Bw
Neal
________________________________
From: Evidence based health (EBH) <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Sent: Fri Mar 12 21:19:31 2010
Subject: Re: What does EBM behaviour look like in real life clinical practice?
Dear Ben,
Whilst we are on this subject of doing more good than harm, you might be interested to know that the inventor of the PSA test for prostate cancer screening Prof Richard Ablin, in a very recent op-ed in the NY Times, today regrets his invention and rues how it has led to a multi-billion dollar profit driven public health disaster in the USA .
He writes 'I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.'
You can read the entire editorial at the following web-link:
http://www.nytimes.com/2010/03/10/opinion/10Ablin.html
We really need to start looking at our own profession very critically now.
Regards,
Ash
Dr Ash Paul
Medical Director
NHS Bedfordshire
21 Kimbolton Road
Bedford
MK40 2AW
Tel no: 01234795705
Email: [log in to unmask]
________________________________
From: "Djulbegovic, Benjamin" <[log in to unmask]>
To: [log in to unmask]
Sent: Fri, 12 March, 2010 19:24:04
Subject: Re: What does EBM behaviour look like in real life clinical practice?
I think Marartje spotted one of the key problems for science of measurement of quality of care: normatively, EBM refers to behavior that is "consistent with evidence" of doing more good than harm (or, practicing according to "best" evidence according to the popular Sackett's definition of EBM.
However, what is the "best" evidence, or what behavior is "consistent with evidence" is revisable exercise and will always be subjected to change reflective of scientific advances (as well as remain open to various interpretative views ..)
ben
Benjamin Djulbegovic, MD, PhD
Professor of Medicine and Oncology
University of South Florida & H. Lee Moffitt Cancer Center & Research Institute
Department of Medicine
Chief, Division of Evidence-based Medicine and Health Outcomes Research
Co-Director of USF Clinical Translation Science Institute
Director of USF Center for Evidence-based Medicine and Health Outcomes Research
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Jim Walker
Sent: Friday, March 12, 2010 10:08 AM
To: [log in to unmask]
Subject: Re: What does EBM behaviour look like in real life clinical practice?
Hi Marartje.
To complicate your problem, I'll note that much of my work as a healthcare informatician is building evidence into my organization's policies, procedures, and health IT.
To the extent that these efforts are successful, evidence-based behavior may be no more than, e.g., responding to a prompt (ideally an implicit one) to diagnose the appropriate level of a patient's asthma (which places the patient on an evidence-based care plan) and using the asthma-level-specific order set to remind myself what medications, patient education, etc. are typically appropriate and select those that are appropriate based on this patient's unique situation and preferences. In an even more automated mode, evidence-based behavior may be embedded in a policy that produces automated interventions, e.g., if a patient's GFR drops below 60 and the patient has not been seen by a nephrologist, a consult is automatically scheduled.
So, in a sense, one form of evidence-based behavior may be the decision to join a healthcare organization that works to build evidence-based healthcare into all its policies, workflows, and electronic information systems. Certainly, one of my commitments to my colleagues is that our health IT will reflect the evidence while at the same time supporting the ability of physicians to adapt that evidence to each patient's needs and preferences.
(This may well be more pertinent in the United States than elsewhere, where evidence-based healthcare may be more generally distributed.)
Cheers!
Jim
James M. Walker, MD, FACP
Chief Health Information Officer
Geisinger Health System
If the human mind was simple enough to understand, we'd be too simple to understand it.
- Emerson Pugh
>>> "Swennen, M.H.J." <[log in to unmask]> 3/12/2010 6:43 AM >>>
Dear all,
My name is Maartje Swennen and I am a PhD student at the University Medical Centre Utrecht in The Netherlands.
Could anyone help me to translate the theoretical definition of EBM (e.g. Sackett, Guyatt) into the (diverse!) ways of how doctors interpret EBM and do (not) apply evidence in routine clinical practice?
For example, a doctor could prefer to answer his/her clinical questions by means of guidelines/protocols, or Pubmed (original articles or reviews), or by asking a colleague, or by reading a book about it, or a trial and error approach, or ......
When do we actually speak of EBM-behaviour?
For example, what is the right balance between using clinical expertise and using evidence?
It is difficult to ask doctors if they follow the five steps, because depending on the frequency of the problem at hand and depending on their interpretations and preferences they will do only a part of the five steps. Sometimes that is good enough, sometimes it is not.
Is there a threshold we could use to judge the EBM behaviour as good enough in routine clinical practice?
Moreover, could we capture this into one or more multiple choice questions?
The more I try to capture EBM behaviour the more difficult it seems to get! Can anyone be of help in this?
Many thanks!
Kind regards, Maartje Swennen
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