These two articles are off the beaten path for this blog, but not off of my beaten path:
by Joanne ReeveBritish Journal of General Practice. 2010 60[576: 521–523.
Quality of decision making in modern health care is defined with reference to evidence-based medicine. There are concerns that this approach is insufficient for, and may thus threaten the future of, generalist primary care. We urgently need to extend our account of quality of knowledge use and decision making in order to protect and develop the discipline. Interpretive medicine describes an alternative framework for use in generalist care. Priorities for clinical practice and research are identified.hat tip to jamzo…
I went to medical school a product of my sputnik generation youth and a mathematical bent – it was the science. And but for the intervention of the US government, I would’ve likely ended in a lab full of the fun machines of science – I sure enjoyed them. But sentenced to practicing medicine, I liked that more and ended up traveling a much different road. As many versions of that story as I can tell, the central word was relevant – it felt relevant. And later, when I left academics a second time, that time less by choice than sailing the winds of the hour, I felt it again [once the storm passed]. So as much as I love the objectivity of the lab and its numbers, there is an appeal to clinical medicine that transcends all else for me – sounds kind of melodramatic, but it’s true.
The other thing I’ve noticed is that whatever clinical medicine means, it is site and specialty independent. I’ve been in lots of settings wearing many hats, but they all seem like they’re part of the same thing – more similar than different. And that includes the appalachian charity clinic where I now volunteer some – a different clientelle from the medically ill, the inner-city poor, the chronic mental patients, the urban heavily-educated, etc of former days. No, I’m not going to wander off on some 60s speech about people all being, after all, people. In fact, the people are all different. It’s clinical medicine that’s the same.
And so to the article above. It’s hard to be a physician and argue against evidence-based medicine. I mean, what’s the alternative? non evidence-based medicine? But we all know the term has taken on a less general meaning in recent times. Dr. Reeve begins:
Evidence-based medicine [EBM] was first described as an approach to teaching the practice of medicine. Twenty-five years on, it has become an assumed standard of ‘best’ or even ‘reasonable’ practice. EBM recognised a need to support healthcare professionals in maintaining an up-to-date working account of the ever-expanding scientific knowledge about illness and health care. Defined as the ‘judicious application of best evidence in making clinical decisions about this individual’, EBM acknowledges both the value and necessity of external research evidence integrated with clinical expertise in clinical decision making. Good doctors use both; neither alone is enough. EBM describes an ‘ideal of practice’ and few GPs would reject a principle of evidence-informed decision making.
While she’s writing as a generalist to other generalists, her words are for us all. It’s as good a discussion of the topic as I’ve read. Dr. Healy does a good job with it in Pharmageddon and his blogs, coming from a different direction. I would say it more simply, clinical medicine is not a Clinical Trial. Not even close. What’s important about what Dr. Reeve has to say comes between that opening paragraph and her ending [which is this]:
The legitimate use of knowledge is a defining aspect of modern clinical practice, and shapes ideas about quality in practice. The ability to integrate knowledge to provide individualised care should be seen as a marker of quality in generalist practice. The profession should be judged not purely by what knowledge it uses, but by the way it uses it. We therefore need to shift the gaze from easier to measure but limited accounts of practice based on the application of certain knowledge to a more appropriate assessment of knowledge use, in order to strengthen and preserve core elements of the discipline and promote and support the health needs of the public.
It’s all on-line for the reading. I looked up some more of Dr. Reeve’s writing and ran across this [also available on-line and worth the moment]:
by Karasz A, Dowrick C, Byng R, Buszewicz M, Ferri L, Olde Hartman TC, van Dulmen S, van Weel-Baumgarten E, and Reeve J.British Journal of General Practice. 2012 62[594]:e55-63.
BACKGROUND: Efforts to address depression in primary care settings have focused on the introduction of care guidelines emphasising pharmacological treatment. To date, physician adherence remains low. Little is known of the types of information exchange or other negotiations in doctor-patient consultations about depression that influence physician decision making about treatment.AIM: The study sought to understand conversational influences on physician decision making about treatment for depression.DESIGN: A secondary analysis of consultation data collected in other studies. Using a maximum variation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected from datasets collected in three countries. Transcripts were analysed to discover factors associated with prescription of medication.METHOD: The study employed two qualitative analysis strategies: a micro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problem presentation.RESULTS: Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative form of the problem presentation. Three types of narratives were identified: those emphasising symptoms, those emphasising life situations, and mixed narratives. Physician decision making regarding medication treatment was strongly associated with the form of the patient’s narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments.CONCLUSION: Results of the study provide insight into why adherence to depression guidelines remains low. Data indicate that patient agendas drive the ‘action’ in consultations about depression. Physicians appear to be guided by common-sense decision-making algorithms, emphasising patients’ views and preferences.
A thoughtful person, Dr. Joanne Reeve. Relevant…
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