Shall we dance?

One of the themes that surfaced frequently during the second (and last) day of this conference evolved around EBHC in resource constrained settings. There were some brilliant suggestions on how to overcome challenges to practicing EBHC (such as lack of internet access or lack of access to information); some thought-provoking success stories on implementation of EBHC practices in these settings; as well as the repeated emphasis that healthcare decisions should be made within the context of the health system, the available resources and the patient’s values.

The very last plenary session of the conference addressed just this: The role of the patient in healthcare decision-making. Dr Victor Montori gave an excellent presentation on Patient-centred Evidence-based Health Care. He reminded us of one of the principles that Dr Gordan Guyatt referred to yesterday: The evidence is never sufficient (which he also referred to as the “ironic principle of EBHC”). When we define EBHC, we stress that EBHC is the combination of clinical expertise, best current evidence and patient values – it is not only about the evidence. But are healthcare practitioners really paying any attention to this component of EBHC? According to Victor Montori, this is the neglected part of EBHC – all around the world.

How do healthcare professionals (HCP) characterise patient values and their unique context as individuals? Do they really know what patients are feeling? Think about the life of a healthcare professional and that of a destitute patient – there is such an enormous difference between these contexts that it would be arrogant to pretend to know what the patient values and what it is like to live in his world.

So how are healthcare decisions made?

Victor Montori described the following decision-making models:

There is the paternal model, where the HCP tells the patient what to do and hence makes the final decision – in which case there is definitely no EBP.

If you want to practice EBHC, you need to adopt another model.  There is the informed model, where the HCP gives the patient all the technical information, the patient verbalises what he wants to do and the HCP provides the evidence for that choice.

There is also the clinician-as-perfect-agent model, where the HCP provides all the necessary information, asks the patient questions about his context, his values and preferences, etc. and advises the patient on what to do. This would also be regarded as EBP, since the HCP does his best to get all the information from the patient.

Shared decision-making is a fictional model (according to Victor Montori), where the HCP and the patient share information, values, pro’s, con’s and ultimately come to a consensus on what should be done. This would be EBP – if it would happen in the real world.

Ideally, there should be a dance across models, a partnership between the individual patient and the HCP – this is called empathic decision-making. In this model, the HCP evaluates the patient and assesses whether he wants to make the decision himself or not; whether there is a difference in opinions and values; and how this differs. The skill lies in the ability to distinguish between these kind of patients, to adopt the appropriate model and to get it right with most patients. It is all about creating opportunities for conversation, asking questions and engaging with the patient.

How can decisions then be made together? Victor Montori proposed a three-step approach:

Step 1: Team and choice talk – this should emphasise that the HCP and the patient are a team and that they are going to make a decision together

Step 2: Option talk – during this step, the HCP presents all the different treatment options to the patient

Step 3: Decision talk – making the decision on what treatment to follow.

The essential part lies between step 2 and 3: the deliberation phase. This is the time the patient needs (which may take a couple of days) to consider all the treatment options, the evidence (as presented by the HCP), his values, preferences and context, as well as his support system and resources. This is where decision-aids come in as very useful tools to create conversations and to illustrate risks and benefits of different treatment options. These should make use of pictures and colours, should be easy to understand and should definitely not contain jargon.

Victor Montori and his team have created a few of these decision-aids, which are freely available on the internet eg. Statin Choice (http://statinchoice.e-bm.info) or Diabetes decision aid (http://diabetesdecisionaid.mayo-clinic.net) and are based on evidence. This is thus an excellent way of incorporating clinical expertise, evidence and patient values in the decision-making process.

Do we teach our healthcare students how to dance?

As good as it gets

It is hard to believe that this was actually only the first day of this exciting conference! Needless to say, it was a day filled with superb plenary sessions, including some by Paul Glasziou and Gordan Guyatt; very interesting oral as well as poster presentations; meeting people from all over the world (although 2/3rds of delegates are from India) and sharing EBHC experiences; and last but not least a delicious Indian dinner where we had the opportunity for more networking and mingling on a more social level.

What I found particularily innovative was one of the poster presentations on how clinical librarians help doctors do EBHC in large hospitals in the UK. Clinical Librarians? Until today, I did not know that they existed, although I think it is a fabulous idea: These are librarians who work alongside the healthcare professionals in the clinical field. Amongst other things, they attend wardrounds (armed with an iPad) to look up any evidence that is needed to answer questions – at the bedside! I really think this is great: no more excuses of not having time to look up the evidence (as you have an expert right by your side) or about not having searching skills, access to information at the bedside etc.

This is as good as it gets for clinicians. And yes, they still need to be taught EBHC skills.

EBM is a way of life…

…or is it a subject?

This was one of the questions raised at the pre-conference workshop on “EBM curriculum development” that I attended today. I must admit that this threw me a little – of course it is a subject!?! It is a way of life too, but surely students need to learn what it is all about before they adopt it as a way of life?

As you can imagine, this turned into quite a discussion. Some people firmly believe, that EBHC should not be taught to undergraduates – as a subject. They should, however, be exposed to it through the way their teachers role model EBHC. Assuming that undergraduate students adopt the clinical behaviour of their teachers, this would lead to them ultimately practicing EBHC. Therefore, it would be most important to teach EBHC to the lecturers and clinicians, so that they can become good role models. But surely this then becomes a subject again? And – how easy is it to convince senior clinicians to change the way they make clinical decisions (and teach these to students)?

Another question related to undergraduates was raised: Should they know how to critically appraise different types of studies, or should they only know how to access synthesised research and summaries thereof found in databases like  Up-to-date and The Cochrane Library? Some people thought that we should be teaching “information mastery” instead of EBHC to undergraduates.

Others argued, that EBHC teaching and learning fits better into the postgraduate curriculum, where students would be more receptive to the principles of EBHC and have a better understanding of how EBHC could be used in practice… but what about those graduates that never continue their studies? This would mean that they would never be exposed to formal EBHC training, unless they attended CME courses. Would this be adequate?

There were also other delegates who believe, like me, that EBHC should be introduced early in the medical curriculum – so that it can be integrated in clinical teaching and ultimately become a way of life. This teaching should continue at postgraduate level. Medical graduates, whether they continue studying or not, should be competent in asking questions, searching for literature and critically appraising the literature. They should also be aware of existing summaries and how to access these – but I do not think this is sufficient.

There are different opinions and certainly a lot of questions that remain when we think about teaching EBHC to students. I really liked the way one of the delegates described it: Learning EBHC is like learning how to drive a car: at first, you think about every step: clutch control, when to change gears, how to park etc. Uuntil it becomes an automatic, intuitive process you can almost do in your sleep. A curriculum on EBHC can thus be seen as the keys to this car, an essential component to ignite EBHC learning.

I think EBHC should start as a subject for every health care student – so that it can become a way of life.

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In the afternoon, I had some time to explore Delhi – This is the tomb of Humayun

 

 

 

ISEHCON 2012

My name is Anke Rohwer and I work at the Centre for Evidence-based Health Care (CEBHC), Stellenbosch University. I will be attending the First International Conference on Evidence Based Healthcare in New Delhi from 6 to 8 October 2012. This inaugural Conference of the International Society for Evidence-Based Healthcare (http://www.isehc.net) aims to provide a platform for EBHC experts and enthusiasts, educationalists and policy-makers to interact, discuss current issues, share challenges and success stories and promote healthcare that is shown to be effective, efficient and affordable.

On behalf of the CEBHC, I will be presenting three posters at the conference.

Follow my blog if you want to share my experiences of this exciting event. Like our Facebook page (www.facebook.com/cebhc) to keep in touch with this and other relevant activities of the CEHBC.