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Information Mastery TM

Information Mastery TM. Using Evidence to Guide Practice. A bit of thinking (and a few simple sums). What will we have learnt?.

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Information Mastery TM

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  1. Information MasteryTM Using Evidence to Guide Practice A bit of thinking (and a few simple sums)

  2. What will we have learnt? • Be more comfortable with an evidence based approach to clinical practice (but understand that finding the evidence doesn’t mean that patients automatically get optimum treatment) • Understand some of the common terms and techniques used • Be able to ask some relevant questions when presented with published research • Be aware of some of the skills required to use summaries of evidence in consultations • Be able to look for useful and easily available evidence when faced with a clinical problem

  3. The Cunning Plan EBM – failure or success? - implementation How are clinical decisions made? How is knowledge found -and used in consultations • Information Mastery • finding summarised evidence • skills to understand summaries The Consultation - Risk communication - Shared decision making Additional evidence supporting the approach

  4. Structure Module 1 • EBM – success or failure? • Implementation approaches – do they work? • How are clinical decisions made? • How is knowledge found -and used - in consultations? • What would something better look like? Module 2 • Information Mastery • Finding summarised evidence • Understanding it (Sums) Module 3 • The Consultation • Risk communication • Shared decision making

  5. The ConsultationRisk communicationShared decision making First the doctor told me the good news: I was going to have a disease named after me. Steve Martin

  6. Level 3-4 diagnostic skills The New Generalist Pinwheel Aware of diagnostic cognitive biases; uses baseline probability and decision rules routinely Can work in biomedical, anticipatory and hermeneutic relationships with patients (ICE) Finds and understands the strength and the language of summaries of evidence from trusted sources Translates that evidence for patients, uses DAs appropriately, discusses OICJ routinely

  7. A 53 year old accountant presents with 6m of worsening hot flushes; she has had no period for 12 months. Her sister found HRT invaluable at the menopause – but recent publicity brings her to you asking for a clear description of the risks and benefits of HRT. 1. What is your understanding of the benefits and harms from HRT? (She wants numbers) 2. How do you communicate those risks?

  8. She produces this data from the Internet • 29% increase in heart attacks • 41% increase in stroke • 26% increase in breast cancer • 211% increase in blood clots • 37% reduction in colon cancer • 34% reduction in fractures

  9. And then she produces this data from the Internet • 10,000 women; 5y of combined HRT; average 63y • 8 extra people with breast cancer • 7 extra heart attacks • 8 extra strokes • 17 extra blood clots • 8 fewer bowel and uterine cancers • 10 fewer hip fractures • 30 fewer other fractures

  10. Traditional medical model • History • Examination • Working diagnosis • Investigations • Confirmed diagnosis • Treatment / management / follow up

  11. Doctors talking to Patients Byrne and Long 1976 • Dr establishes relationship with patient • Dr discovers / attempts to discover reason(s) for attendance • Dr conducts verbal or physical examination, or both • Dr, Dr and patient, or patient (in that order of probability) consider the condition • Dr, and occasionally patient, details treatment or further investigation • Consultation terminated, usually by Dr.

  12. The Future GPHorder J (Ed).The Future General Practitioner. Learning and Teaching by a Working Party of The Royal College of General Practitioners. RCGP. 1972. • Problem presented • Problem examined • Problem defined • Solution proposed • Solution examined • Solution implemented

  13. Stott and DavisThe exceptional potential of each primary care consultation. JRCGP 1979; 29: 201-205 • Management of presenting problems • Modification of help seeking behaviour • Management of continuing problems • Opportunistic health promotion

  14. Pendleton’s seven tasksD Pendleton et al, The Consultation: an Approach to Learning and Teaching, 1984 • Define reason for attending including • Nature and history of problems • Their cause • Patient’s ideas, concerns, and expectations • The effect of the problems • Consider other problems • Continuing problems • At risk factors • Choose with the patient an appropriate action for each problem • Achieve a shared understanding of the problems with the patient • Involve the patient in the management and encourage him / her to accept appropriate responsibility • Use time and resources appropriately • In the consultation • in the long term • Establish or maintain a relationship with the patient which helps achieve other tasks

  15. NeighbourThe Inner Consultation, MTP, 1987 • Connecting • have we got rapport? • Summarising • could I demonstrate to the patient that I've sufficiently understood why he's come: • the patient's reason for attending • the patient's ideas and feelings, concerns and expectations are explored and acknowledged adequately • listening and eliciting • the clinical process - assess, diagnose, explain, negotiate and agree • Handing Over • has the patient accepted the management plan we have agreed? • Safety netting • What if...? General practice is the art of managing uncertainty: • predict what could happen if things go well • allow for an unexpected turn of events • plans and contingency plans • Housekeeping • Am I in good condition for the next patient? - stress, concentration and equanimity

  16. Calgary-CambridgeSM Kurtz and JD Silverman. Medical Education 1996; (30): 83-89 A.Initiating the session i) Establishing initial rapport ii) Identifying reasons for attendance B.Gathering information iii) Exploring the problems iv) Understanding the patient's perspective v) Providing structure to the consultation C.Building the relationship vi) Developing the rapport vii) Involving the patient D.Giving information - explaining and planning viii) Providing the right amount and type of information ix) Aiding accurate recall and understanding x) Achieving a shared understanding: incorporating the patient's perspective xi) Planning: shared decision-making E.Closing the session

  17. Calgary-CambridgeSM Kurtz and JD Silverman. Medical Education 1996; (30): 83-89 iv) UNDERSTANDING THE PATIENT'S PERSPECTIVE 13. Ideas and concerns: explores and acknowledges the patient's ideas (beliefs about causation) and concerns (worries) regarding each problem. 14. Effects: finds out the effects on the patient's life. 15. Expectations: finds out what help the patient had expected for each problem. 16. Feelings and thoughts: encourages the patient to express feelings and thoughts. 17. Cues: picks up verbal and non-verbal cues (body language, facial expression and affect) and checks and acknowleges them appropriately.

  18. Calgary-CambridgeSM Kurtz and JD Silverman. Medical Education 1996; (30): 83-89 viii) PROVIDING THE RIGHT AMOUNT AND TYPE OF INFORMATION Aims: To give comprehensive and appropriate information To assess the individual's information needs Not to restrict or overload 30. Assimilable: explains in chunks, checks understanding and uses the reponse as a guide to how to proceed. 31. Starting point: checks the patient's prior knowledge early on. 32. Other needs: asks what else is wanted (prognosis, aetiology etc). 33. Appropriate timing: avoids giving advice, information or reassurance prematurely.

  19. Calgary-CambridgeSM Kurtz and JD Silverman. Medical Education 1996; (30): 83-89 ix) aiding recall and understanding Aims: To make information easier to remember and understand 34. Logical: subdivides information and presents it in sequence. 35. Markers: uses explicit categories and signposts ('There are three important things.. Now shall we move on to..') 36. Reinforces information: repeats information and summarises. 37. Clarity: uses concise, easily understood statements and avoids or explains jargon. 38. Visual methods: uses diagrams, models and written information and instructions. 39. Feedback: checks understanding of information and plans by, for example, asking the patient to restate in own words; clarifies if necessary.

  20. Calgary-CambridgeSM Kurtz and JD Silverman. Medical Education 1996; (30): 83-89 xi) planning: shared decisions Aims: To allow the patient to understand the decision-making process To involve patients in decision-making to the level they wish To increase patients' commitment to the plans made 44. Shares own thoughts: reveals the doctor's own ideas, thought processes and dilemmas. 45. Suggests: involves the patient by making suggestions rather than directives. 46. Encourages: draws out the patient to contribute their own thoughts (ideas, suggestions and preferences). 47. Negotiates: negotiates a mutually acceptable plan. 48. Offers choices: encourages patients to make choices and decisions to the level they wish. 49. Checks with patient: ensures that all concerns have been addressed and that the plans are acceptable.

  21. The Doctor-Patient relationship • Sociological model • Drs and patients have beliefs based on norms and values of their peers; behaviours based on and consistent with these • Anthropological model • Illness behaviour based on patient trying to explain e.g. ‘why now’, why to me’. (ICE) • Transactional model • Berne E. Games people play. Parent, adult and child • Psychological model • Variable health motivation, perceived vulnerability, perceived seriousness of the problem,perceived costs and benefits. Behaviour based on these beliefs • Internal locus of control vs external locus of control

  22. The Doctor-Patient relationship • Verbal model • Verbal patterns established early • Non-verbal model • E.g. Non verbal messages inconsistent with verbal • Balint (1957) • Psychological and physical problems are intertwined • Doctors have feelings, and these are a function • Doctors vary in their awareness of these

  23. So what is a good consultation?Gilles JCM. RCGP Occasional Paper 86. 2005 • Biomedical model • Scientific, mending broken mechanisms • Duty of care, longevity & fertility • Individual focus only, illness detached from life of the patient • Anticipatory Care Model • Illnesses have origins in behavioural patterns (J Tudor Hart) • Scientific, but population focussed • Is autonomy respected? • Teleological or Hermeneutic model • Purpose may be to help patient understand illness

  24. Where do you think is the median? Clinician led decisions Patient led decisions

  25. Where do you think is the median? Clinician led decisions Patient led decisions

  26. A 53 year old accountant presents with 6m of worsening hot flushes; she has had no period for 12 months. Her sister found HRT invaluable at the menopause – but recent publicity brings her to you asking for a clear description of the risks and benefits of HRT. 1. What is your understanding of the benefits and harms from HRT? (She wants numbers) 2. How do you communicate those risks?

  27. She produces this data from the Internet • 29% increase in heart attacks • 41% increase in stroke • 26% increase in breast cancer • 211% increase in blood clots • 37% reduction in colon cancer • 34% reduction in fractures

  28. And then she produces this data from the Internet • 10,000 women; 5y of combined HRT; average 63y • 8 extra people with breast cancer • 7 extra heart attacks • 8 extra strokes • 17 extra blood clots • 8 fewer bowel and uterine cancers • 10 fewer hip fractures • 30 fewer other fractures

  29. 2 key steps • Ideas, concerns, expectations • E.g. • “I can see you’re bothered by those symptoms, what do you think is causing it?” • “Do you have any thoughts about what this might be?” • “Have you read or heard about the way this is treated these days?” • Options • Implications • Choice • Justification (by reference to the evidence base)

  30. A key medical decision maker: The patient: Deyo R. BMJ 2001; 323: 466-467 • Many medical decisions fall into a grey area where the optimal choice for an individual patient may be unclear and where reasonable people might choose differently. • Research suggests that Decision Aids improve patient knowledge, reduces decisional conflict, and stimulates patients to play a more active part in decision-making without increasing their anxiety. • DAs make a revolutionary contribution to medical decisions simply by making it clear that there often is a choice.

  31. Making decisions about benefits/harms of medicinesGreenhalgh T, et al. BMJ 2004; 329: 47–50 • Acceptable risk: • some risks appear more acceptable than others. • ‘acceptable’ hazards tend to be more familiar, perceived as under the individual’s control, have immediate rather than delayed consequences and are linked to perceived benefits. • Anchoring: • in the absence of objective probabilities, people judge risk according to a reference point. • this may be arbitrary – for example, the status quo or some perception of what is “normal”. • Availability bias: • events that are easier to recall are judged more likely to happen. • recall is influenced by recency, strong emotions, and anything else that increases memorability (media coverage, personal experience).

  32. Making decisions about benefits/harms of medicinesGreenhalgh T, et al. BMJ 2004; 329: 47–50 • Categorical safety and danger: • people may perceive things as either good or bad irrespective of exposure or context. • this may make them unreceptive to explanations that introduce complexity into the decision. • Appeal of zero risk: • elimination of risk is more attractive than reduction. • Framing of information: • describing the glass as half empty or half full can significantly alter perceptions. • losses loom larger than gains.

  33. Making decisions about benefits/harms of medicinesGreenhalgh T, et al. BMJ 2004; 329: 47–50 • Illusionary correlation: • prior beliefs and expectations about what correlates with what, leads people to perceive correlations that are not in the data. • Distinguishing between small probabilities: • we cannot meaningfully compare between very small risks, for example between 1 in 20,000 and 1 in 200,000. • expressing harm as relative rather than as absolute risk dramatically shifts the subjective benefit:risk balance. • Personal vs. impersonal risk: • health professionals and patients may have different preferences perhaps due to different knowledge about outcomes and inherent differences in making decisions about oneself or others. • those making decisions about others tend to be prepared to take more risks than those making decisions about themselves.

  34. Making decisions about benefits/harms of medicinesGreenhalgh T, et al. BMJ 2004; 329: 47–50 • Preference for the status quo: • most people are reluctant to change current behaviours, even when the objective evidence of benefit changes. • it may be due to persistence of illusionary correlation. • Probability vs. frequency: • poor decision making is exacerbated by the use of absolute and relative probabilities. • judgement biases are less common when information is presented as frequencies.

  35. Principles of communicating risksPaling J. BMJ 2003; 327: 745-748 • Patients’ assessments of risk are primarily determined by emotions not by facts • Communicate the trade off between benefits and harms • Avoid purely descriptive terms of risk e.g. “low risk” • Use a consistent denominator e.g. 1 in 100, 5 in 100; not 1 in 100, 1 in 20. • Use absolute numbers (not relative) • Use visual aids and probabilities

  36. http://bmj.bmjjournals.com/talks/simplicity_and_complexity/index_files/frame.htmhttp://bmj.bmjjournals.com/talks/simplicity_and_complexity/index_files/frame.htm Suppliers of information to doctors—and doctors themselves when informing patients—must grapple with complexity to deliver a message of such simplicity that it aids decision making and prevents adverse outcomes Kamran Abassi

  37. Everything should be made as simple as possible, but not simpler Albert Einstein

  38. Treatment of menopausal symptoms: what shall we do now? Hickey, et al. Lancet 2005; 366: 409-421 Annual risks and benefits after 5 years of combined HRT 7 years of oestrogen-only HRT Numbers in bars are increased or decreased risk per 10 000 women

  39. Edwards A. Doctor. 11 Dec 2003

  40. Edwards A. Doctor. 11 Dec 2003

  41. What would happen to 100 people like you who take sleeping tablets for more than a week. For 76 people the tablets do NOTHING, good or bad These SEVEN people sleep better, which means they get an extra 25 minutes sleep a night! They also wake up once less every 2 nights These SEVENTEEN people have side effects One of them may be serious, like a fall or car crash

  42. TugwellP, et al. BMJ, Jun 2004; 328: 1362-1363

  43. The “pill scare”Current Problems in Pharmacovigilance 1999; 25: 12 In 1995, four observational studies found that, overall: Risk of venous thromboembolism per year None pill users 5 in 100,000 2nd generation pill users 15 per 100,000 3rd generation pill users 25 per 100,000 Pregnancy 60 in 100,000 Risk of dying on the road is about 6 in 100,000 (Bandolier) CSM advice is now that these agents can be used as first-line agents and that ‘it is a matter of clinical judgement and personal choice which type of oral contraceptive should be prescribed’

  44. Antibiotics for bronchitisLittle P, et al. JAMA 2005; 293: 3029–3035

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