Which statement best describes your attitude toward patient care

[drusso]

We've all taken plenty of multiple choice tests in our time.

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[hyperalgesia]

Some things will never be surrendered.

 

[Papa Lou]

I voted with pts too...but i disagree it will never change. It already is changing. The results spread is between "system" and "patient." This is justifiable and it is new thinking. System numbers will eventually overtake patient numbers. It seems medicaid is forcing this at a rapid rate...which is bad for them, but maybe good for the majority within the healthcare-dollar ecosystem.

 

[101N]

You left out evidence-based care.

 

[geauxg8rs]

If Dr Oz was voting he would side
With evidence based care

 

[drusso]

You left out evidence-based care.

Everyone agrees that evidence-based care is tantamount.

 

[101N]

But that's not true. Some would argue that patient satisfaction trumps EBM, or that
physician autonomy trumps EBM, or physician/institutional bottom line trumps EBM,
or that grant volume ($) trumps EBM, or that consensus trumps EBM.

 

[Ducttape]

the problem with this question is that it is trying to impose absolutes in situations where there are shades of grey.

all of us are patient advocates. i would argue that any physician that does any prior auths is automatically a patient advocate. however, all of us are cognizant what the patients limitations, the limitations of their insurance, the limitations of the system we work in, etc.

with that being said, i would say 70% patient advocate, 20% community advocate, 5% employer(who is the system), and 5% other...

 

[101N]

"i would say 70% patient advocate"

So, playing devils advocate, lets say that 60% of your patients are working-aged medicaid,
with the typical mix of 1/3rd opioid seeking, 1/3rd disability seeking, and 1/3rd with central
sensitization. Advocacy from the patient's perspective then translates to: an opioid Rx when
not indicated, a disability endorsement when not indicated, and enablement of continued
dysfunction and resignation from healthy life roles.

I think we need to be advocates for evidence-based care. Patients often aren't.

 

[drusso]

But that's not true. Some would argue that patient satisfaction trumps EBM, or that
physician autonomy trumps EBM, or physician/institutional bottom line trumps EBM,
or that grant volume ($) trumps EBM, or that consensus trumps EBM.

I can't think of any article or leader in our field that has staked their reputation on that claim: Could anyone persuasively argue to eschew EBM?

 

[drusso]

"i would say 70% patient advocate"

So, playing devils advocate, lets say that 60% of your patients are working-aged medicaid,
with the typical mix of 1/3rd opioid seeking, 1/3rd disability seeking, and 1/3rd with central
sensitization. Advocacy from the patient's perspective then translates to: an opioid Rx when
not indicated, a disability endorsement when not indicated, and enablement of continued
dysfunction and resignation from healthy life roles.

I think we need to be advocates for evidence-based care. Patients often aren't.

Why would a decent person advocate for something harmful or not indicated? That would be cruel and/or sociopathic...I think that you're conflating the ideas of advocacy and acquiescence...it would be like saying, "I never deviate from guidelines no matter what the situation." No one agrees with that statement.

 

[101N]

As Duct suggested you are WAY over-simplifying things. There are aways competing agendas from
all sides. You are quick to note the financial agendas of insurance companies and hospital systems.
But PP physicians also have agendas, some not as nobel as EBM or advocacy. Moreover, our friends
in the ivory towers also have their own agendas: grant money, ego, publications. And patients have
agendas as well.


http://www.bmj.com/content/347/bmj.f5889?etoc=


Everyone lies. In their CVs, job applicants always were the captain of the football, hockey, or something-else team at school; played three musical instruments, normally at the same time; enjoyed debating; were head boy or girl; and had also done good work in Africa (a continent overflowing with poorly constructed toilet blocks built by hapless, unskilled, never-made-a-bed teenagers). Truths, half truths, and lying are the stock and trade of life. I am always skeptical of what is written until I can eyeball the author for truthfulness.


Daniel Pelka died last year, aged 4, at the hands of his mother and her partner. He joined a long list of high profile cases dating back decades, including Peter Connelly, Victoria Climbié, Brandon Muir, Maria Colwell, and Dennis O’Neill. Many other forgotten children never received this attention.


The recently published serious case review into Daniel’s death highlights missed opportunities by professional agencies to intervene. Doctors can aspire to do better.


In this situation Daniel’s mother had lied, explaining away signs of abuse as medical conditions, such as an eating disorder and learning difficulties. The report into Daniel’s death encouraged professionals to “think the unthinkable” and to be more questioning of parents’ explanations.1 This runs counter to our culture of trust. But it shouldn’t.


Patients lie to doctors all the time for drugs, certificates, or referrals. Tears, demands, threats, complaints, anger, hostility, and defensiveness are the indicators of manipulation and lying. Patients from all backgrounds lie, though sometimes in different ways: aggression is aggression however passively and politely expressed. Women and men are both capable of aggression, manipulation, and dishonesty; most fabrications of illness in children are perpetrated by mothers.2 This isn’t cynicism but realism.


Much of medicine isn’t very nice; some is downright unpleasant. Doctors must learn to trust and distrust in equal measure. Interpret body language, be suspicious of inconsistencies, and understand that the unbelievable story is unbelievable for a reason. Many of us have learnt this from bitter experience, at school, in different jobs and relationships, from the wise words of our elders, and of course in clinical practice. Medical practice demands that we use our intuition. Medical training must be more honest, and it should make clear the harshness of work.

 

[drusso]

As Duct suggested you are WAY over-simplifying things. There are aways competing agendas from
all sides. You are quick to note the financial agendas of insurance companies and hospital systems.
But PP physicians also have agendas, some not as nobel as EBM or advocacy. Moreover, our friends
in the ivory towers also have their own agendas: grant money, ego, publications. And patients have
agendas as well.


http://www.bmj.com/content/347/bmj.f5889?etoc=


Everyone lies. In their CVs, job applicants always were the captain of the football, hockey, or something-else team at school; played three musical instruments, normally at the same time; enjoyed debating; were head boy or girl; and had also done good work in Africa (a continent overflowing with poorly constructed toilet blocks built by hapless, unskilled, never-made-a-bed teenagers). Truths, half truths, and lying are the stock and trade of life. I am always skeptical of what is written until I can eyeball the author for truthfulness.


Daniel Pelka died last year, aged 4, at the hands of his mother and her partner. He joined a long list of high profile cases dating back decades, including Peter Connelly, Victoria Climbié, Brandon Muir, Maria Colwell, and Dennis O’Neill. Many other forgotten children never received this attention.


The recently published serious case review into Daniel’s death highlights missed opportunities by professional agencies to intervene. Doctors can aspire to do better.


In this situation Daniel’s mother had lied, explaining away signs of abuse as medical conditions, such as an eating disorder and learning difficulties. The report into Daniel’s death encouraged professionals to “think the unthinkable” and to be more questioning of parents’ explanations.1 This runs counter to our culture of trust. But it shouldn’t.


Patients lie to doctors all the time for drugs, certificates, or referrals. Tears, demands, threats, complaints, anger, hostility, and defensiveness are the indicators of manipulation and lying. Patients from all backgrounds lie, though sometimes in different ways: aggression is aggression however passively and politely expressed. Women and men are both capable of aggression, manipulation, and dishonesty; most fabrications of illness in children are perpetrated by mothers.2 This isn’t cynicism but realism.


Much of medicine isn’t very nice; some is downright unpleasant. Doctors must learn to trust and distrust in equal measure. Interpret body language, be suspicious of inconsistencies, and understand that the unbelievable story is unbelievable for a reason. Many of us have learnt this from bitter experience, at school, in different jobs and relationships, from the wise words of our elders, and of course in clinical practice. Medical practice demands that we use our intuition. Medical training must be more honest, and it should make clear the harshness of work.

Well. I think that you're describing very "touchy-feely" things like values, discernment, integrity, curiosity, character, and authenticity. Hippocrates believed that these were the sine qua non of the physician-patient relationship and the foundation of medical professionalism. I'm not certain any EBM paradigm addresses those things. In fact, EBM is supposed to be "value-neutral" in that regard. The "data" being an end unto itself...I wonder if the attraction to "system-thinking" narrative for some physicians is more about a validation of a certain kind of intellectual laziness..."I don't have to think or discern or judge, just follow the rules."

“Our starting point is not the individual: We do not subscribe to the view that one should feed the hungry, give drink to the thirsty, or clothe the naked … Our objectives are different: We must have a healthy people in order to prevail in the world.”

― Joseph Goebbels

 

[SSdoc33]

Well. I think that you're describing very "touchy-feely" things like values, discernment, integrity, curiosity, character, and authenticity. Hippocrates believed that these were the sine qua non of the physician-patient relationship and the foundation of medical professionalism. I'm not certain any EBM paradigm addresses those things. In fact, EBM is supposed to be "value-neutral" in that regard. The "data" being an end unto itself...I wonder if the attraction to "system-thinking" narrative for some physicians is more about a validation of a certain kind of intellectual laziness..."I don't have to think or discern or judge, just follow the rules."

“Our starting point is not the individual: We do not subscribe to the view that one should feed the hungry, give drink to the thirsty, or clothe the naked … Our objectives are different: We must have a healthy people in order to prevail in the world.”

― Joseph Goebbels

Godwin's Law? You're better than that......

 

[drusso]

Godwin's Law? You're better than that......

Goebbels falls under the exception to Godwin's Law: He plagarized Stalin...

 

[Ducttape]

part of being a patient advocate is also to be cognizant that that which is bad for the patient should not be prescribed. with regards to the above, i would argue that one is not being an appropriate advocate for the patient when considering these nonproductive and damaging interventions such as opioids, disability,etc.

"With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage." how one decides (ie my judgement and means) should be through EBM.

additionally, 101 brings up a major point that is constantly glossed over on these forums - everyone, including PP physicians, have agendas.

 

[SSdoc33]

Goebbels falls under the exception to Godwin's Law: He plagarized Stalin...

ahh. my mistake.

i thought you were quoting a bad man. stalin is clean as a whistle.

 

[Ducttape]

wikipedia mentions that one of the corollaries of Godwin's Law is that the person who posits the comparisons to Nazism is by default the "loser" of the thread.


so, im sorry, drusso. You're out.

 

[oldanddone]

You left out evidence-based care.

The evidence for evidence based care is actually quite slim.

 

[101N]

So back to Brownian medicine, heh?

 

[oldanddone]

http://m.cfp.ca/content/59/11/1160.full?sid=9a0f1b11-fea3-4c50-a450-c2c91011ae09

 

[Ducttape]

a position paper to refute evidence based medicine is oxymoronic, to say the least. their reasoning is so pre-Y2K.

"Disciplined scepticism, context-sensitive reasoning, and humane attention to patient needs should be the skills we hold in highest regard. Evidence-based medicine is overrated in family practice because it fails to teach these skills."

a patient will use these skills to justify cigarette smoking, driving without a helmet, not taking prescribed medications or failing to follow doctors prescriptions.


"I only smoke after ive taken a ride on my cycle without my helmet, cause im so anxious and revved up after almost getting my skull smashed into 95 tiny pieces by that big 18 wheeler. after the calming effect of the cig goes away, rather than take another, ill take a hit of weed with oxycontin to get long lasting benefit - because i need it and its only in this situation that i do it..."

 

[oldanddone]

The paper states that there is no evidence for good or better outcomes with ebm. So that's your challenge if youchoose to accept it. And that smoking cyclist? It's what's out there so how will you meet tst person half way? Ebm doesn't teach that as much as the challengers such as patient focused paradigms. And the reference to polypharmacy and the elderly is also key. Follow all the ebm guidelines and then delouse with beers criteria.

 

[drusso]

...additionally, 101 brings up a major point that is constantly glossed over on these forums - everyone, including PP physicians, have agendas.

Here is how it works : research changes policy, policy changes payment, payment changes practice.

Hmm...I wonder if it really works that way: When I meet with the health care central planners in my region, I'm not hearing a lot of spirited debate about the limits of high quality evidence informing practice. I don't even hear a lot of high minded pablum about the importance of being a skeptical reader of the literature, or being an advocate for patients, or the sanctity of the patient-physician relationship, or the call of service to the medical profession...they mostly just talk about money (how to spend less of it) and control (how to get more of it).

 

[Ducttape]

The paper states that there is no evidence for good or better outcomes with ebm. So that's your challenge if youchoose to accept it. And that smoking cyclist? It's what's out there so how will you meet tst person half way? Ebm doesn't teach that as much as the challengers such as patient focused paradigms. And the reference to polypharmacy and the elderly is also key. Follow all the ebm guidelines and then delouse with beers criteria.

1. why do we have to meet this person half way? Why do we have to compromise on our ethics to make the person happy? We should be their medical conscience, not compromising and be someone who is trying to make the patient feel happy and carefree about their dangerous choices.
2. there are plenty of examples of ebm causing better outcomes. those who deny the benefit of ebm choose to ignore the facts of medicine that we know.
For example:
a. MMR vaccine reduce incidence of those diseases
b. Tetanus reduces risk of this disease
c. smoking cessation reduces risk of death from cardiac and stroke
d. diabetic medications reduce the risk for hyperglycemic complications.
e. wearing a helmet reduces risk of fatal head injury for motorcyclists.
f. not driving drunk reduces risk of automobile related fatality.
g. wearing seat belt reduced risk of ejection, and 3 out of 4 people who are ejected die from injuries.
etc.

3. i fail to understand your point about Beers criteria. the Beers criteria are based on EBM, are they not?

4. so go ahead, be touchy feely, make patients feel better, do your patient focused paradigms. i for one prefer to see patients in follow up in the office, not the funeral home.

5. ive done a lot of career pathways, but this is probably the reason i never considered FP...

 

[oldanddone]

1. Who is 'we'. Take personal responsibility for your positions.

2. You have listed individual studies which are all shining examples. You have not commented on the utility of ebm as a paradigm to use...Ie Pico on every patient issue thst comes through your door.

3. Is it???? Not so sure about that. Some ebm but also some good first principles. And ongoing research that would be low hanging fruit....duh less meds is more in terms elderly.



4. If they see you at all. So a practice of type a rule followers. From your perspective there could be worse. Sounds like a workable plan.

5. Yes you would likely not have what it takes for family medicine. Good choice.

 

[Gauss]

Here is how it works : research changes policy, policy changes payment, payment changes practice.

Hmm...I wonder if it really works that way: When I meet with the health care central planners in my region, I'm not hearing a lot of spirited debate about the limits of high quality evidence informing practice. I don't even hear a lot of high minded pablum about the importance of being a skeptical reader of the literature, or being an advocate for patients, or the sanctity of the patient-physician relationship, or the call of service to the medical profession...they mostly just talk about money (how to spend less of it) and control (how to get more of it).

in private they talk about the money, in public it's about the patient/consumer "experience"

 

[Ducttape]

we "is" you and i and all physicians who have direct patient care.

you and i dont have to compromise our ethics - unless i guess you are in FP, in which case your thought leaders feel you should, and you follow their non-EBM guidelines based on, well...

i practice PICO with every patient encounter. i dont call it that. although all patients essentially get referral for CBT and PT, the focus is on improving a particular patients quality of life through safe and effective treatment that is individualized and has EBM support. (fyi there is database support - as can be found in Cochrane database - to suggest that CBT and home exercise have benefit. PT referral is to assist in developing this home exercise program.)

no series of 3. no ESI for purely axial dominant pain. no RFA without physical exam and diagnostic MBB. etc.

So a practice of type a rule followers

huh?

finally, with respect to Beers Criteria, the 2012 version from AGS includes support for recommendations from EBM: http://www.guideline.gov/content.aspx?id=37706

Guideline Objective(s)

• To improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs)
• To update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events (ADEs) in older adults

...
Description of Methods Used to Collect/Select the Evidence
Literature Search

The literature from December 1, 2001 (the end of the previous panel's search) to March 30, 2011, was searched to identify published systematic reviews and meta-analyses that were relevant to the project. Search terms included adverse drug reactions, adverse drug events, medication problems, polypharmacy, inappropriate drug use, suboptimal drug therapy, drug monitoring, pharmacokinetics, drug interactions, and medication errors. Terms were searched alone and in combination. Search limits included human subjects, English language, and aged 65 and older. Data sources for the initial search included Medline, the Cochrane Library (Cochrane Database of Systematic Reviews), International Pharmaceutical abstracts, and reference lists of selected articles that the panel co-chairs identified.

The initial search identified 25,549 citations, of which 6,505 were selected for preliminary review. The panel co-chairs reviewed 2,267 citations, of which 844 were excluded for not meeting the study purpose or not containing primary data. An additional search was conducted with the additional terms drug–drug and drug–disease interactions, pharmacoepidemiology, drug safety, geriatrics, and elderly prescribing. An additional search for randomized clinical trials and postmarketing and observational studies published between 2009 and 2011 was conducted using terms related to major drug classes and conditions, delimited by more general topics (e.g., adverse drug reactions, Beers Criteria, suboptimal prescribing, and interventions). Previous searches were used to develop additional terms to be included in subsequent searches, such as a list of authors whose work was relevant to the goals of the project. When evidence was sparse on older medications, searches were conducted on drug class and individual medication names and included older search dates for these drugs. The co-chairs continually reviewed the updated search results for articles that might be relevant to the project. Panelists were also asked to forward pertinent citations that might be useful for revising the previous Beers Criteria or supporting additions to them.

At the time of the panel's face-to-face meeting, the co-chairs had selected 2,169 unduplicated citations for the full panel review. This total included 446 systematic reviews or meta-analyses, 629 randomized controlled trials, and 1,094 observational studies. Additional articles were found in a manual search of the reference lists of identified articles and the panelists' files, book chapter, and recent review articles, with 258 citations selected for the final evidence tables to support the list of drugs to avoid.

Number of Source Documents
A total of 258 citations was selected for the final evidence tables.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Quality of Evidence


Designation Description
High Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes (≥2 consistent, higher-quality randomized controlled trials or multiple, consistent observational studies with no significant methodological flaws showing large effects)
Moderate Evidence is sufficient to determine effects on health outcomes, but the number, quality, size, or consistency of included studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes (≥1 higher-quality trial with >100 participants; ≥2 higher-quality trials with some inconsistency; ≥2 consistent, lower-quality trials; or multiple, consistent observational studies with no significant methodological flaws showing at least moderate effects) limits the strength of the evidence
Low Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher-quality studies, important flaws in study design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
The panel split into four groups, with each assigned a specific set of criteria for evaluation. Groups were assigned as closely as possible according to specific area of clinical expertise (e.g., cardiovascular, central nervous system). Groups reviewed the literature search, selected citations relevant to their assigned criteria, and determined which citations should be included in an evidence table. During this process, panelists were provided copies of abstracts and full-text articles. The groups then presented their findings to the full panel for comment and consensus. After the meeting, each group met in a conference call to resolve any questions or to include additional supporting literature.

An independent researcher prepared evidence tables, which were distributed to the four criteria-specific groups.

 

[oldanddone]

It's very different worlds. But it often doesn't cut as fp/specialties. Often the harder it is to bridge with a patient and the more necessary it is creates different approaches and that is true of all clinics. Once a patient hears the evidence, that is only the start and not where the relationship ends with referral and dispo. Until ebm opens itself to many an academic discourse currently excluded, this all may sound unintelligible or lacking intelligence or whatnot. Or even unethical from a certain viewpoint. But many would not be included in that homogenous 'we'.

 

[lobelsteve]

It's very different worlds. But it often doesn't cut as fp/specialties. Often the harder it is to bridge with a patient and the more necessary it is creates different approaches and that is true of all clinics. Once a patient hears the evidence, that is only the start and not where the relationship ends with referral and dispo. Until ebm opens itself to many an academic discourse currently excluded, this all may sound unintelligible or lacking intelligence or whatnot. Or even unethical from a certain viewpoint. But many would not be included in that homogenous 'we'.

Unsure if a person typed this or a thesaurus vomited. Not one coherent statement conveyed.

 

[Ducttape]

i suspect what he is saying is that FP is different from all other specialties; he might present the EBM to the patient, but then he has to acquiesce - ie work with - to the patient's whims, because he has to bridge and some relationship with the patient.

unlike internal medicine, emergency medicine, anesthesiology, and pain medicine (where i have personal experience), where EBM and safe medical practices are the starting point, and relationship building is centered first and foremost on the premise that medical care will be safe, beneficial and based on sound practice confirmed with EBM.

at least, i do agree with this statement: "this all may sound unintelligible or lacking intelligence".

 

[101N]

If oldanddone is, in too many words, suggesting EBM + a shared decision making model then fine.

 

[oldanddone]

A little more than that. But we will leave it there.

 

[oldanddone]

i suspect what he is saying is that FP is different from all other specialties; he might present the EBM to the patient, but then he has to acquiesce - ie work with - to the patient's whims, because he has to bridge and some relationship with the patient.

unlike internal medicine, emergency medicine, anesthesiology, and pain medicine (where i have personal experience), where EBM and safe medical practices are the starting point, and relationship building is centered first and foremost on the premise that medical care will be safe, beneficial and based on sound practice confirmed with EBM.

at least, i do agree with this statement: "this all may sound unintelligible or lacking intelligence".

I thought you might agree with that. The other specialties cited often don't follow ebm. Hence the whole movement to 'choose wisely' and not practice 'cya medicine'. Ebm is not the whole picture in many specialties for many reasons.