Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Personal knowledge: an observation of decision making in practice.
- Simon C Crawford (23 January 2006)
-
Don't ever take a fence down until you know why it was put up.
- BM Hegde (23 January 2006)
-
Personal Knowledge
- Neil F Hockings (25 January 2006)
-
There are more things ...
- Iona Heath (26 January 2006)
-
Numbers needed to poison
- james n hardy (26 January 2006)
-
A developing country perspective on personal knowledge and medical blogs as tools for personal knowledge sharing
- Irina Haivas, Prof. Traian Mihaescu, Editor BMJ Romania, "Gr.T.Popa" University of Iasi, Romania (30 January 2006)
-
Once bitten twice shy
- Stavros N Prineas (6 February 2006)
-
Knowledge is not just personal but collective
- John Gabbay, Andree le May (11 February 2006)
-
From knowledge to clinical practice - How can we increase the involvement of health professionals?
- Albert Figueras, Edgar Narváez (28 September 2006)
|
|
|||
|
Simon C Crawford, consultant gynaecological surgeon Southampton Hospitals University Trust, Southampton, SO16 5YA, UK.
Send response to journal:
|
Could I propose an observation that clinicians' decision making is determined by; the evidence, personal experience and one's 'last worse case': in reverse order. Competing interests: None declared |
|||
|
|
|||
|
BM Hegde, Retired Vice Chancellor Mangalore-575 004, India
Send response to journal:
|
Dear Editor, Robert Frost, the American poet, wrote that line years ago. Why was this "evidence based" tag put up in the first place? In retrospect, I believe it was there to give respectability to Pharma. Lobby’s efforts. Let us take this simple drug, warfarin, a rat poison in larger doses, in therapeutics. This drug has never ever been tried in combination with any other drug during its development. In real life warfarin is usually used in combination with digoxin, beta-blockers, ACE inhibitors, nitrates, statins, antibiotics and a host of other drugs in a single patient. Where is the evidence to show that this drug is safe and is active in that combination? In fact, no drug has ever been tried in combination. Almost all drugs are tried singly under ideal circumstances in patients who are carefully monitored. After that drug is let lose on the gullible public, it is used rarely ever, if ever, in isolation. No one could then have guidelines for use based on research. What then is this tall talk about "evidence based medicine"? It is in fact evidence burdened medicine. I am not trying to pull down the fence of evidence base. I am only trying to show why it was put up in the first place. “To hit the mark,” wrote Henry Wadsworth Longfellow, “you must aim a little above it. Every arrow that flies feels the attraction of earth.” Yours ever, bmhegde Competing interests: None declared |
|||
|
|
|||
|
Neil F Hockings, Consultant Physician Nobles Hospital IM4 4RJ
Send response to journal:
|
I was disappointed to read Kieran Sweeney's editorial commenting on the paper concerning anticoagulation and atrial fibrillation. Surely the point is not how we learn but how we get people to follow guidelines which are based on sound evidence. I assume that the doctors whose prescribing was affected by recent personal experience with patients who had had bleeding complications of warfarin treatment were supposed to be following a guideline on the management of atrial fibrillation. This being so what we need to think about is how to persuade prescribers to follow these guidelines. The theories of learning described by Dr Sweeney are irrelevant. The learning has already taken place as a result of numerous clinical trials defining the benefits and risks of treatment. Individual experience should not affect future adherance to agreed and up to date guidelines based on current knowledge of the subject. The message of the editorial should have been to comply with the guidelines and not allow personal recent experience to affect your judgement and thus put future patients at risk by not giving them the optimal treatment. Competing interests: None declared |
|||
|
|
|||
|
Iona Heath, general practitioner Caversham Group Practice NW5 2UP
Send response to journal:
|
Dr Hockings' view of clinical practice (rapid response 25 January 2006) is frighteningly reductive. We know that the degree to which the physician believes in the efficacy of the treatment has a measurable effect on the outcome – as does the colour and form of medication, the reputation of medicines resulting from advertising or other forms of publicity, the relationship between the patient and the physician, and the attitude of the physician to the patient(1). All doctors are affected by the deaths of their patients and any doctor who has signed a prescription which appears to have led directly to the death of a patient is almost certain to have misgivings about that particular medication. If they did not, one might reasonably question their sensibility and their humanity. Yet, if the doctor is wary or fearful of a medication, the patient is proportionately likely to fare less well. There are no simple answers to this complex predicament. Further Dr Hockings ignores the knowledge that medical science has yet to acquire. The human brain has a hugely sophisticated capacity for pattern recognition. The doctor who declines to prescribe for a patient whose presentation or appearance evokes someone who has suffered a previous serious adverse effect may well be recognising a subtle genetic or environmental predisposition which has not yet been recognised. As a patient, I would much rather be treated by Dr Sweeney who is open to a variety of different ways of knowing rather than Dr Hockings who seems determined to confine his understanding to a single modality of evidence. 1 Moerman D. Meaning, medicine and the ‘placebo effect’. Cambridge: Cambridge University Press, 2002. Competing interests: None declared |
|||
|
|
|||
|
james n hardy, GP principal Bethnal Green Health Centre, 60 Florida Street, London E2 6LL
Send response to journal:
|
Editor Evidence-based medicine can seem like a grey amorphous sludge when you’re in the middle of a consultation - small wonder then to discover that doctors find it hard to tow the line as Choudhry (1) and Sweeney (2) have cleverly pointed out. The evidence may be there but we choose not to believe it, or perhaps we may believe something else based on our experience. So what is it that helps us make decisions with our patients? If it is experience, then how reliable is a meta-analysis of anecdote, for is not experience just a collection of anecdotes? I think it is a balance between the number needed to treat (NNT) and the number needed to poison (NNP) – the former can never be more than a paper exercise because we never will know what illness we have prevented – we will only know what has happened, that to say, what is tangible. The following case illustrates this well. My GP Registrar rattles off the conclusions of the latest European secondary stroke prevention trial. P + A does the business better than P or A alone, and the NNT is only 18. Some time later an elderly patient we started on P + A comes back to the surgery. She slams the packet down on my desk and says, “I’m not f…ing taking anymore of them”. It takes some time to placate her. Shortly afterwards I get a call from anxious relatives. I struggle to explain the concept of prevention within the context of what has happened. Indeed, I am barely convinced myself because the number needed to treat may only be 18, but, this gives us 18 separate opportunities to poison a patient. It is no surprise that anecdote is so powerful, nor is it a great surprise to know that the pharmaceutical industry, whilst funding most of the large trials that inform evidence-based medicine, is not only aware of our susceptibility to anecdote, but also to the general publics’ susceptibility to anecdote based medicine. (1) Choudry NK et al. Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis. BMJ 2006;332: 141-3 (2) Sweeney K. Personal knowledge. BMJ 2006; 332: 129-130. Competing interests: None declared |
|||
|
|
|||
|
Irina Haivas, final year medical student "Gr.T.Popa" University, Iasi 6600 (Romania), Prof. Traian Mihaescu, Editor BMJ Romania, "Gr.T.Popa" University of Iasi, Romania
Send response to journal:
|
In the editorial on “Personal Knowledge”1, Dr. Sweeney argues about the "under-recognized notion of personal knowledge in clinical practice” and "the two ways of knowing: biomedical and biographical”. Coming from a low-resource setting, we feel that personal knowledge, although more subjective and not peer-reviewed, is also very important and we would like to bring a developing world perspective to this debate. Personal knowledge is essential when you do not have access to all diagnostic and treatment tools from the international guidelines. We are of course aware of the importance of evidence based medicine, but the lack of resources does not always allow us to put it into practice. Still, we have managed to achieve positive results-resources balance, and the fact that we use personal knowledge played a big part in this. It is satisfying for us to see that the medical world considers restoring the value of personal biographical knowledge. As one proof, we would like to point out to medical blogs. Today we have the enormous potential of technology (including internet), to help us share and use the personal knowledge; a thousand years ago, we wrote it on papyrus, now we have the chance to write it on medical blogs. A blog (weblog) is a website in which journal entries are posted on a regular basis. They are free of charge, only online, and personal Medical blogs started out as online diaries of health professionals but some of them evolved into real means for medical educational and science communication. These contain a lot of valuable insights in practicing clinical medicine. They also have a sense of real life that many doctors could find motivating and easier to read than a journal article. They are no subject to any rules, which means freedom for the author. Despite the debates around medical blogs (for instance, peer review vs unfiltered online publication), we think they hold potential as way of exchanging information between the developed and the developing world. The fact that blogs are online and free of charge makes them more accessible for doctors in low-resource settings, as compared for instance to the cost of a medical journal subscription or of attending an international medical conference. Doctors in the developing world publish less in high rank journal as compared to their counterparts from developed world, but the reasons for this are not that they do not have data or experiences to write about. Getting online and publishing a blog would be an easier way for these doctors to share their personal knowledge. Countries like ours manage to deal with serious diseases such as TB or the current avian flu threat with significantly less resources and despite a weaker infrastructure and health system. We see certain kind of conditions or advanced stages of disease that don’t occur so often in the developed world. We can also bring a different social perspective, that of the complex social issues caused by lower standards of living. These are all sources of important personal knowledge. The developed world might benefit from this personal knowledge of the developing world and medical blogs are a one opportunity that should not be overlooked. We do not say that blogs should replace medical journals, but rather that they should complement it. For this, they need to be acknowledged and accepted, and people need to be made aware of their potential, also in regard to the developing countries. We have many young enthusiastic doctors, open to the new developments, willing to learn and to share. We feel that other forms as knowledge sharing, such as medical journals or oral presentations, should see blogs not as competition, but as “partners” in the way to ensure a wide access to complete and complex information. 1. Kieran Sweeney. Personal knowledge. BMJ 2006; 332: 129-130 Competing interests: None declared |
|||
|
|
|||
|
Stavros N Prineas, consultant anaesthetist Bathurst Base Hospital Australia 2795
Send response to journal:
|
EDITOR - In his editorial on ‘Personal Knowledge’ (1) Dr Sweeney describes the availability heuristic as ‘a fancy way of saying that we are more like to recall events which are more easily recalled’. However in my view this simplification is not only off the mark, it robs the reader of its true significance in relation to the article by Choudhry et al.(2) on adverse events and warfarin prescribing. In cognitive psychospeak, a heuristic is a ‘rule of thumb’(3) , a guide to making quick assessments and decisions, usually based on past experience or self-directed trial and error. There are many heuristics that people (including doctors) invoke to inform their decisions, because most of the time they lead to the best option. The most common is the frequency heuristic or ‘frequency gamble’ – known to most doctors as ‘common things occur commonly’, or ‘if you hear hooves, it’s probably a horse’ (the trick is knowing when you’re in the Serengeti). The availability heuristic (4) refers to the decision maker being influenced by the ‘most available’ or ‘memorable’ past scenario that matches the situation at hand. There are several kinds of events that tend to ‘stick’ in our mind – the first time we did something (primacy), the last time we did something (recency), the time that had the greatest emotional impact (affect), among others. Choudhry’s article illustrates a natural and very human phenomenon – that when an event occurs that affects us personally (a severe bleeding event in a patient under my care on warfarin that I prescribed), it can have a significant effect on future decision making that outweighs evidence or reasoning. Another by-product of the ‘affect heuristic’ if that if we really like a drug or a technique for whatever reason, we tend to emphasise its benefits and downplay the risks. Conversely, if we come to dislike a drug or a technique, we emphasise the risks and downplay the benefits. (5) Furthermore once a view is entrenched in our mind, we tend to heed evidence that supports our view and filter or ignore evidence that contradicts it (confirmation bias)(6) . When a severe adverse event shakes our emotional attitude to a drug, the same cognitive biases that upheld the use of the drug then disfavour it, with evidence either way taking a back-seat. These are cognitive biases that all humans are prone to, and take awareness and effort to overcome. I agree with Dr Sweeney that as a profession we should devote more attention to the underexamined subject of doctors’ risk perception and decision-making. Finally, with the revolutionary benefits that modern pharmacy undoubtedly brings, it is perhaps easy to forget that virtually all modern drugs are some form of poison, and while it may not always be appropriate to fear them it would be healthy to accord them due respect. In the Choudhry article, the risk of severe bleeding events while on warfarin therapy was quoted as 3.4%. Out of interest, what was the corresponding risk of stroke and other severe thromboembolic events in the other cohort (not quoted in the article)? Stavros Prineas
1. Sweeney K. Personal Knowledge. BMJ 2006; 332: 129-30 2. Choudhry NK, Anderson GM et al. Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis. BMj 2006;332: 141-3 3. Weiten W. Psychology : Themes and Variations. (4th Edition – Brooks Cole pubs.) 1998; p 318 4. Tversky A, Kahneman D. Availability: A heuristic for judging frequency and probability. Cognitive Psychology 1973; 5: 207-232 5. Finucane ML, Ahakami A et al. The affect heuristic in judgements of risks and benefits. In The Perception of Risk (Slovic P ed., Earthscan pubs.) 2000; 413-429 6. Reason J. Human Error 1990; p89 (Cambridge University Press) Competing interests: Dr Prineas runs a human factors training consultancy |
|||
|
|
|||
|
John Gabbay, Emeritus professor Wessex Institute for Health R&D SO16 7PX, Andree le May
Send response to journal:
|
It is good to see that the topic of personal knowledge found its way to a lead editorial (1): anything that can be done to raise awareness about this important feature of clinical thinking and decision making is very welcome. It is after all now nearly half a century since Michael Polanyi formulated his views (2), which are so germane to understanding how doctors and other clinicians use evidence in practice and, as Sweeney so elegantly argues, how practitioner and patient negotiate their respective views of a clinical problem. However, as we have exemplified elsewhere (3), we cannot afford to ignore the deeply social nature of personal knowledge. In our ethnographic studies we have found that what others have called the "view from somewhere" (4) seems to derive principally from continual interactions with the clinicians’ "communities of practice" (5) and with other key “actors” (6) in their network, which the person cannot easily recall or identify. Without understanding these social interactions that collectively reinforce a view of appropriate practice, we will not understand how personal knowledge is constructed. We coined the term “mindlines” (3) to describe the collectively reinforced, internalised, tacit guidelines that clinicians use in practice because as we understand them, the psychologists’ terms, “heuristics”, “rules of thumb” and “scripts” all describe simple cognitive short-cuts that people use in common situations. But we have found that in order to guide their practice clinicians actually internalise much more complex - and socially constructed – knowledge derived from a vast array of sources. If we are to improve the ways in which the best evidence can be incorporated into daily practice, we need to explore not just personal knowledge, but also its social construction. 1. Sweeney K. Personal knowledge BMJ 2006; 332: 129-130 2. Polanyi M. Personal knowledge: towards a post-critical philosophy. London: Routledge and Kegan Paul, 1958. 3. Gabbay J, Le May A. Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care BMJ 2004;329:1013 4. Nagel T. The view from nowhere” Oxford: Oxford University Press 1986 5. Wenger E. Communities of practice: learning, meaning and identity. New York: Cambridge University Press, 1998. 6. Latour B. Science in action: how to follow scientists and engineers through society. Boston: Harvard University Press, 1988. Competing interests: None declared |
|||
|
|
|||
|
Albert Figueras, Manager, International Cooperation Area Fundació Institut Català de Farmacologia. U. Autònoma de Barcelona (08035 - Barcelona, Spain), Edgar Narváez
Send response to journal:
|
Six years ago the Nicaraguan government asked us to implement treatment guidelines (TGs) for the most prevalent health problems of the country in six-months. Speed and products use to be the two main preoccupations of politicians and managers, hurried by their moneylenders. After some discussion, a stepwise development of a post-partum haemorrhage (PPH) TG was selected as a training example. Several Nicaraguan institutions had already published TGs for PPH, but the real management of delivery differs from their recommendations. The causes seemed simple: TGs are written far from the clinical reality and usually imposed, what translates into low adherence. In order to bridge this gap, a crucial step consists in getting the clinicians involved with the elaboration of the TGs. The starting point is a drug utilisation study (DUS) whose results, after being socialised with the clinician, are the stimulus to realise what is happening in real practice, to ask why things happen, and to look for answers, adapting evidences into TGs. PPH is a condition with well-known and affordable management, and such a high incidence in less developed countries (1) seems not justifiable. Furthermore, inefficacy of ergometrine in extreme heat and humidity conditions when appropriate conservation cannot be ensured was described more than 20 years ago (2). Despite the published evidences, this information seems not to have reached the target professionals, as it continues to be widely used in hospitals where it is stored at room temperature (3). In the current century of information, oversaturation is easy. Health professionals should be reading 19 scientific articles each day of the year to keep updated (4). The gap between scientific knowledge and the real health professionals’ knowledge increasingly widens: lack of time is combined with difficult access to information and, sometimes, idiomatic barriers. Some professionals simply ignore that a prescription habit is obsolete or wrong; additionally, not all relevant clinical evidences are reaching the prescribers. Without the use of doubting about one own prescribing habits, it is difficult to identify practices that need to be updated. The healthy habit of doubting could be implemented stimulating DUS. Despite being observational, DUS help to clarify doubts in clinical settings, to introduce research habits among clinicians, and to stimulate the information seeking process to reduce the know-do gap. This kind of capacity building should be encouraged because contributes to improve personal knowledge (5) and adherence to TGs. Independent digested information and continuous medical education further improve prescription. The latter, although not universally considered a worthwhile investment by Health Authorities, at least seems better than leaving it in hands of drug industries (6). Not surprisingly, in the same Nicaraguan hospital where ergometrine was inappropriately used, doctors were asking to include the last ‘sartan’ in the country’s essential drug list —a petition that would deepen inequalities. Authors: Albert Figueras, MD Manager of the International Cooperation Area - Fundació Institut Català de Farmacologia. Assciate Profesor - Universitat Autònoma de Barcelona. Hospital Vall d’Hebron, E-08035 – Barcelona (Spain) afs@icf.uab.es Edgar Narváez, MD Manager of the Technical Unit of Medical Evaluation - Instituto Nicaragüense del Seguro Social, Managua (Nicaragua) enarvaez@inss.org.ni Acknowledgements A grant of the Agència Catalana de Cooperació al Desenvolupament is helping to develop a Latin-American Network Against Maternal Mortality (GIRMMAHP; http://www.girmmahp.net) an intervention based upon the discussed considerations. Competing Interest: "All authors declare that the answer to the questions on your competing interest form (http://bmj.com/cgi/content/full/317/7154/291/DC1) are all No and therefore have nothing to declare" References: (1) United Nations Population Fund. State of the World Population 2004. The Cairo Consensus at Ten: Population, reproductive health, and global effort to end poverty. UNFPA, New York, 2005. http://www.unfpa.org/upload/lib_pub_file/327_filename_en_swp04.pdf (last accessed, September 28th, 2006). (2) Walker GJ, Hogerzeil HV. Potency of ergometrine in tropical countries. Lancet 1988;2:393. (3) Figueras A, Narváez E, Aguilera C, Laporte JR. Securing reproductive rights. Lancet 2004;363:989. (4) Rawlins M. St. Paul International Health Care Annual Lecture on Sept. 7th, 1999 http://www.nice.org.uk/page.aspx?o=27856 (last accessed, September 28th, 2006). (5) Sweeney K. Personal knowledge. Doctors are much more than simple conduits for clinical evidence. Br Med J 2006;332:129-30. (6) Anonymous. Drug companies influence on medical education in USA. Lancet 2000;356:781. Competing interests: None declared |
|||