“Can anyone tell us how we use a calculation of ‘Likelihood of Help versus Harm’ (LHH) to incorporate patients’ values in our decisions?”
My question was met with blank stares. Some of the assorted Masters’ students shifted uncomfortably in their seats. I, their teacher, was just as uneasy. The room was clammy (it was, after all, summertime in Hong Kong). But this wasn’t the cause of our discomfort. Page 129 of our recommended text (Sackett DL, Straus SE, et al., editors. Evidence-Based Medicine; How to practice and teach EBM. 2nd ed: Elsevier, 2000) offered reassurance: ‘We’ve found that the LHH can be used in the busy clinical setting (median time to complete 6.5 minutes), is intelligible to both clinicians and patients, and is unambiguously patient-centred.’ We all knew this was fanciful given the complex, tangled jungle that is real-world practice. From my own experience as a GP, I knew I was leading my students down a rabbit hole, dug with great enthusiasm by the clinical epidemiologists from McMaster, who first coined the term ‘Evidence-Based Medicine.’ I contemplated whether Evidence-Based Health Care (EBHC) could be strengthened to meet real-world constraints – particularly in my own specialty of general practice. I also pondered the LHH of my own teaching intervention. It was to take me a little longer than 6.5 minutes.
Advance eleven years, and I’m nearing the end of a DPhil in Evidence-Based Health Care. With the invaluable help of my long-suffering supervisors, a central plank of my thesis has just been published in BMC Medical Education, under the title A real-world approach to Evidence-Based Medicine in general practice: a competency framework derived from a systematic review and Dephi process. After 3 days, the altmetrics for the article are looking healthy. Perhaps many other teachers and learners of EBHC have pondered the same dilemma of translating the discipline for real-world general practice.
We synthesised two sets of themes describing the meaning of EBHC in general practice. One set of themes was derived from a mixed-methods systematic review of the literature. The other set was derived from the further development of those themes using a Delphi process among a panel of EBHC and general practice experts. This resulted in a very simple competency framework, that acknowledges the constraints of real-world general practice:
- Mindfulness in one’s approach towards EBHC itself, and to the influences on decision-making.
- Pragmatism in one’s approach to finding and evaluating evidence.
- Knowledge of the patient, as the most useful resource in effective communication of evidence.
By ‘mindfulness,’ we mean a non-judgemental, global awareness of the physical and mental processes at play in the present moment. For example, it may be late on a Friday afternoon, or we may feel upset about a previous complaint from the patient. By ‘pragmatism,’ we mean a realistic ‘just-in-time’ approach to finding useful, valid evidence by becoming adept at using trusted online sources of ‘pre-appraised’ evidence. ‘Knowledge of the patient’ refers to the unique ability of the GP to ‘read’ their patients, to know instinctively when it is the right occasion to communicate evidence.
Further work is needed. The real-world competency framework requires validation as an educational resource, and as a strategy for actual practice. To breathe life into it, we are exploring its use in the personal development component of the annual performance appraisal. Perhaps there is future potential as a standard section of the online appraisal tools GPs use.
At the 5th International Conference for EBHC Teachers and Developers (Sicily, 2009), Professor Paul Glasziou posed the question: ‘Eighteen years later: is Evidence-Based Practice really adult?’ I believe it has progressed through a rebellious youth, and now in its mid-twenties, it must learn to temper that remarkable energy and passion with real-world wisdom. One way is to recalibrate the educational outcomes we demand of GPs in the post-modern era.
Kevin Galbraith is a part-time DPhil student in Evidence-Based Health Care. To read the full paper, please click here.
Carl Heneghan and Alison Ward for their supervision and helpful discussions, and Kamal Mahtani for help with the Delphi process.