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2005 BMJ MBE and its inherent uncertainty.pdf

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Papers The nature of medical evidence and its inherent uncertainty for the clinical consultation: qualitative study Frances Griffiths, Eileen Green, Maria Tsouroufli Abstract Objective To describe how clinicians deal with the uncertainty inherent in medical evidence in clinical consultations. Design Qualitative study. Setting Clinical consultations related to hormone replacement therapy, bone densitometry, and breast screening in seven general practices and three secondary care clinics in the U
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  Papers  The nature of medical evidence and its inherent uncertainty for theclinical consultation: qualitative study Frances Griffiths, Eileen Green, Maria Tsouroufli Abstract  Objective  To describe how clinicians deal with the uncertaintyinherent in medical evidence in clinical consultations. Design  Qualitative study. Setting   Clinical consultations related to hormone replacement therapy, bone densitometry, and breast screening in sevengeneral practices and three secondary care clinics in the UK NHS. Participants  Women aged 45-64. Results  45 of the 109 relevant consultations included sufficient discussion for analysis. The consultations could be categorisedinto three groups: focus on certainty for now and this test, withslippage into general reassurance; a coherent account of themedical evidence for risks and benefits, but blurring of theuncertainty inherent in the evidence and giving an impressionof certainty; and acknowledging the inherent uncertainty of themedical evidence and negotiating a provisional decision. Conclusion  Strategies health professionals use to cope with theuncertainty inherent in medical evidence in clinicalconsultations include the use of provisional decisions that allowfor changing priorities and circumstances over time, to avoidslippage into general reassurance from a particular test result,and to avoid the creation of a myth of certainty.  Introduction Clinicians have access to a growing body of good clinicalresearch evidence informing them about the effectiveness of many medical interventions. However robust the research, clini-cians face the dilemma of applying this evidence to individualpatients. 1  This is the uncertainty inherent in the nature of medi-cal evidence. For example, epidemiology tells us that smoking isa risk factor for heart attack, but it does not tell us whichindividuals will be affected. 2 Randomised controlled trials of hor-mone replacement therapy 3 report on the number of extra  breast cancers identified in a large number of women receiving treatment compared with those not receiving treatment,but theycannot tell us which women will develop the extra cancers. Thisdilemma between the nature of medical evidence and individualpatient care is central to medicine’s history and will not disappear, as they are essential to each other. Diseases alwaysmanifest themselves in patients’ bodies and minds, and inseeking to understand,treat,and predict the outcome of disease,clinicians need to move their focus from the individual to moregeneralised research. 4 Clinicians recognise this dilemma and have reflected on thisin relation to their clinical practice 2 and the need for researchmethods that give more attention to the particular rather than tothe general. 5  The importance of this dilemma is discussed withinrelated disciplines, including medical philosophy, ethics, andhealth policy. 6–9 Few studies, however, have examined what clini-cians actually say to patients. 10 Studies have considered howclinicians communicate clinical evidence to patients, taking account of their preferences 11 and maintaining the clinician-patient relationship. 12 Studies have also acknowledged thedifficulty of communicating about the risks and benefits of inter- ventions. 13  These studies do not, however, examine communica-tion in relation to the inherent uncertainty in the evidence. Weexamined how health professionals talk to patients about thisuncertainty, and we provide a framework for reflecting on howthey handle the dilemma of applying clinical evidence toparticular patients. Methods  We examined consultations with health professionals in bothprimary and secondary care where there was discussion of oneor more of the interventions of hormone replacement therapy, bone densitometry, or breast screening. Our study includedhealthcare sites in contrasting socioeconomic contexts in theMidlands and north east England. The collection of these data  was part of a larger study,reported elsewhere. 14 15  All women aged 45-64 attending one of seven general prac-tices or three specialist clinics in the UK NHS were invited toparticipate in our study. After consent was obtained, the health-care professional audiotaped the consultations. These werereviewed for their relevance to our study. We discarded those with no mention of the relevant interventions, and we retainedall the others regardless of the extent of the discussion of theinterventions. Table 1 lists the details of the clinics and surgeriesand consultations recorded. The details of the research process,including analysis,are on bmj.com.Overall, 109 consultations were relevant: 73 from generalpracticeand36fromspecialistclinics.Mostwomenattendingtheclinics agreed to be recorded, whereas in general practice theconsent rate was lower (20% in some practices). A key emergent theme was uncertainty and how it isdiscussed between health professionals and women, particularlythe uncertainty inherent in medical evidence when it is appliedto particular patients. The data included 64 consultations withonly a brief mention of the interventions.For example,a womandiscusses with the practice nurse those symptoms she thinks aredue to the menopause, and hormone replacement therapy is Details of the research process are on bmj.com  Cite this article as: BMJ, doi:10.1136/bmj.38336.482720.8F (published 31 January 2005) BMJ  Online First bmj.com  page 1 of 7  mentioned only briefly (also see bmj.com). Owing to insufficient data,we did not include these consultations in subsequent analy-sis. Through a process of discussion and comparison of data, wedeveloped categories for how uncertainty was dealt with in theremaining 45 consultations,which were recorded by 25 different health professionals (nine had more than one consultation inthis dataset and of these, three had more than two). The catego-riesweredevelopedasatoolforunderstandingandreflectingon what was taking place in the consultations. The results of theanalysis were presented to three university based focus groups — two of doctors and one of patients —  which provided feedback onthe validity of the categories from their own experience. Infurther comparative analysis we explored links between howuncertainty was dealt with and the healthcare issues and context. Results  The extract in box 1 provides an example of how uncertaintyowing to the nature of medical evidence was managed within theconsultations; the doctor knows what should make a differenceto bone density based on medical research,but he does not know what has made a difference for this particular woman. The three approaches to the uncertainty inherent in medicalevidence in the consultations were certainty for now, the coher-ent story of certainty,and acknowledgment of the uncertainty. Approaches to uncertainty inherent in medical evidence Certainty for now   The health professionals talked about certainty for now, or for this test  — for example, the result of ultrasonography at the timeof the procedure. However, they also slipped into generalreassurance. Coherent story of certainty  The health professionals wove a coherent account of the medicalevidence for risks and benefits — for example, a great deal of detail, including estimates of the size of risk, was included in a discussion of hormone replacement therapy for osteoporosis. The way in which this detail was delivered, however, gave animpression of certainty,even though the health professional mayhave used words implying uncertainty.  Acknowledging uncertainty  The uncertainty of outcome from using an intervention wasacknowledged,including the inherent uncertainty of the medicalevidence when applied to individuals. A strategy used to cope with this uncertainty was negotiating a provisional decision.Most consultations included elements of each of the threecategories. In all but four consultations, however, a dominant approach to uncertainty was identified. Of the nine healthprofessionals who had more than one consultation, all except one (specialist registrar) used more than one approach to theuncertainty inherent in medical evidence. Certainty for now Health professionals talked of certainty in relation to the resultsof the test they had carried out or were planning. Reassurance was given before the results were available, but with the provisothat the results were needed to be absolutely sure. For example,in two consultations women told their general practitioner about changes in their breasts. The women were examined andreassured that their breasts seemed “normal.” The women werereferred to the breast clinic for further certainty from tests (see box 2,extract 1). A doctor in the breast clinic (consultation 032) emphasisedthe need for certainty by saying “obviously we need to know for sure” and arranged a biopsy to try and achieve that. He followedthis by saying that “often we biopsy things to prove that they’renothing ... we get so many surprises, we’re sort of duty bound tooffer you the . . . chance of biopsy.” The type of certainty being talked about is a test result for the here and now — a particular  Table 1  Number of consultations recorded between health professionalsand women at midlife in which hormone replacement therapy, bonedensitometry, or breast screening was mentioned Setting, health professional No of health professionals No of consultations General practice 1:General practitioner 3 5Practice nurse 2 3General practice 2:General practitioner 3 9General practice 3:General practitioner 4 6Practice nurse 1 2General practice 4:General practitioner 1 3Practice nurse 3 3General practice 5:General practitioner 4 10Practice nurse 1 7General practice 6;General practitioner 2 9Practice nurse 2 13General practice 7:General practitioner 1 1Practice nurse 1 2Hormone replacement clinic:Consultant 1 2Specialist registrar 1 3Breast clinic:Associate specialist 1 2Consultant 1 4Specialist nurse 2 2Bone clinic:Consultant 2 11Specialist nurse 1 1Radiographer 1 11 Box 1:The uncertainty of medical evidence  A follow up bone density reading shows that the patient is“holding her own” — that is, her bone density is not decreasing.Patient: I’m still on the Didronel, should I continue with it, I, Ithought possibly that you might have said come off it now, because I understood that my level was sort of normal for my agenow.Doctor: For your age, that’s correct.Patient: Umm, so I wondered possibly if that’s why I was coming to see you today. You’d maybe say I had to come off it, but if youfeel that I should continue with it I’m quite happy to do that.Doctor: Umm, as long as there’s no problems with it.Patient: If necessary, I don’t have any problems whatsoever.Doctor: Umm, okay. My view would be take a belts and bracesapproach. By that I mean you’ve changed your diet, you’re doing more exercise, those two things are good for you. Err, taking theDidronel we know now is allowed on a long term basis.Patient: Yes.Doctor: Err and I am a little uncertain as to which of these threestrands, the diet, the exercise or the medication, is making thedifference, but something is. (Bone clinic, consultation 054) Papers page2of7  BMJ  Online First bmj.com  piece of tissue at this time. The mention of surprises indicatesuncertainty,but only until the results of the biopsy are known.In the second extract in box 2, the doctor talks about certaintyprovidedbytheultrasoundresultforthebreasttissueat this time and then goes on to explain to the woman the limitednature of this certainty. Other consultations in this category didnot include such explanation.The health professionals took careto tell the women that the particular tissue examined wasnormal, but followed this up with a reassuring phrase which wasrathergeneral — forexample,“it’sperfectlynormal,you’realright”(consultation 031). Coherent story of certainty In some consultations, the health professional wove an account or explanation for the woman that was coherent, almost as a story. The intention seemed to be to provide information andexplanation so that the woman could make her own decisions,although the overall tenor of the consultations was in favour of the intervention. In some of the consultations a great deal of detailed information was provided, including numerical esti-mates of risk and explanations of uncertainty. From the way women responded, however, it seems this formed an unfocused backdrop for their decisions.Inbox3,extract1,boththedoctorandthewomanseemedtostruggle with the uncertainty inherent in medical evidence. Thedoctor actually contradicts himself in the process of trying toprovide a coherent account of the risk of osteoporosis. The woman also struggles to understand how the evidence applies toher. At one point the doctor links his explanation to the experi-ence of the woman’s mother, a reality they both know about.However, most of what the doctor says is drawn from evidence based on populations (much of this detail has been removed for  brevity). The impression this creates is one of certainty about how the evidence applies to this particular woman despite thedoctor using words and phrases that include uncertainty andprobability. The doctor creates a myth about the certainty of theevidence for this woman.Consultations in general practice tended to be shorter thanthose in specialist clinics, with less detail given of the risk and benefits. Some general practitioners expressed certainty about the effect of hormone replacement therapy. For example, in dis-cussing hormone replacement therapy (consultation 008) a patient says “I don’t really want to come off it,if it’s not doing anyharm.” To which the doctor replies “Not, not any harm at all.” In box 3, extract 2, a different general practitioner gives quite a lot of information about the risks and benefits of hormone replace-ment therapy and the different factors to be weighed up for dif-ferent individuals. However, the tenor of the consultation is of  weaving a coherent account that indicates that it is possible for each individual to work out what is best for them with some cer-tainty. Approaches to acknowledging uncertainty In box 4, extract 1, the woman is concerned about the newevidence about hormone replacement therapy. She hasconcludedthattherisksaresmall.Thegeneralpractitionerbacksup the woman’s assessment of the risk and also explains the dif-ficulty of applying population evidence to an individual:“It’s verydifficult to know whether if something happens to you whether it’s this or more likely whether it would have happened anyway.”It then becomes clear that for the woman having energy for her “young lad”is important to her and given priority over the medi-cal risk. A provisional plan is made whereby hormonereplacement therapy will be used for now but then reviewed.It isthrough this provisional approach that the woman and doctor have achieved some integration of future risk from the interven-tion including the uncertainty inherent in the medical evidence, with how things are for the woman in the current time and place.In another consultation (box 4, extract 2) there is agreement of a provisional plan for a reduction in the dosage of hormonereplacement therapy, a suggestion that came from the woman. This plan integrates the concern about future risk from thetherapy with the woman’s experience of symptoms, so linking across the gap between the medical evidence and the woman’sindividual experience.In a consultation with a practice nurse (box 4, extract 3) therisks of hormone replacement therapy are discussed and the woman describes feeling well. The nurse explains the risk of  breast cancer, weaving a coherent story of the risks and benefits. The woman introduces the idea of a provisional decision “bythen I might be okay we’ll just have to wait and see.” They agreeon continuing the therapy for now, aware of the potential risk and of the good quality of life for the woman.In another consultation (005) the doctor tells a woman whohas been receiving hormone replacement therapy for six yearsfor relief of symptoms, has a family history of breast cancer, andhas annual mammography,that her risk of breast cancer is going up: it is about “weighing the two up,” “it becomes personalchoice.” The woman says “Will anybody sort of say ‘hey’ at a cer-tain point? Or will that be up to me?” The doctor says “I think  what you’ll find is that there’ll be conversations like this once in a  while,”indicating that the decision is a provisional one. Use of the different approaches  Analysis of the consultations by role of the health professionaland type of healthcare setting indicates a link between theapproach used for the uncertainty inherent in medical evidenceandthehealthcaresite(table2).Certainty“fornow”wasfoundinthe breast clinic. Weaving a coherent story of certainty predomi-nated in the hormone replacement therapy clinic and boneclinic.General practice used all three approaches.The pattern of approachbecameclearerwhenexploredinrelationtothehealthconcern discussed in the consultations (table 3). In allconsultations where there was concern about a breast problem,health professionals used the approach of certainty for now withslippage into general reassurance.Where the result of bone den-sitometry and subsequent management was discussed, which insome consultations included use of hormone replacement  Box 2:Certainty for now and this test,with slippage intogeneral reassurance Extract 1:Woman mentions changes in her breasts Patient: I just kept putting it to the back of my mind and then it  was just, I thought well its not, it doesn’t feel right you know it  was like pulling and I thought hmmm.Doctor: I’ll sort you out a review at the breast clinic and thenthey’ll be able to reassure you fully I’m, I’m sure . . . (Generalpractice, consultation 094) Extract 2:Woman has ultrasonography of her breasts  During ultrasonography Doctor: Here it is looking very clear that it is an innocent kind of,er, thing. That’s why we don’t need to do any biopsy.  After ultrasonography Doctor: The thing is, it doesn’t exclude you to getting something else some other place . . . that’s the thing. I can tell about  what  —  what is happening today, and about these ones, which look innocent. (Breast clinic, consultation 003) Papers BMJ  Online First bmj.com  page 3 of 7  therapy, most of the consultations used a coherent story of certainty.In the one consultation on this health issue that did not use this approach, further test results were awaited. A coherent storyofcertaintywasalsousedforconsultationswherehormonereplacement therapy was initiated for other reasons. The healthissues were discussed in specialist clinics and in general practiceand by both doctors and nurses. When reviewing the use of hormone replacement therapy or restarting therapy after a break, acknowledging uncertainty pre-dominated.Somehealthprofessionals,however,woveacoherent story of certainty (see table 3). The consultations on this healthissue were all recorded in general practice. No pattern wasapparent linking the category of the consultation and whether the review was initiated by the woman or by the healthprofessional.  Discussion  To achieve good communication between health professionalsand patients,health professionals need strategies for coping withthe dilemma of applying medical evidence to individual patients. These strategies could include using provisional decisions that allow for changing priorities and circumstances over time,avoid-ing slippage into general reassurance from a particular test result,and avoiding the creation of a myth of certainty. Box 3:Weaving a coherent account of the medical evidence for risks and benefits,but with blurring of the uncertaintyinherent in the evidence and an impression of certainty Extract 1:Consultation after bone densitometry Doctor: Your bone mineral density is following the course you would, we would expect.Patient: Right.Doctor: It is going down, you would expect that at this point in the menopause.Patient: So it’s not abnormal then or anything?Doctor: It’s not abnormal.(The woman’s mother has osteoporosis. The doctor explains:) A woman with a close female relative has 30% chance of having osteoporosis just ’cos you know they’re related . . .(The doctor then suggests she considers taking calcium and vitamin D and taking hormone replacement therapy. The woman says “I’venever really been very keen on HRT.” The doctor then examines her and continues:) With the constant, bone loss starts just round the very beginning that the hormones start to change, what we call the perimenopause andthen you’re likely to lose bone well totally predictably to lose bone for about 10 years after the menopause so it will start to gradually comedown. At the moment the results are normal, you have normal bone mineral density but err after about 10 years it’s going to drop into the below normal range, you can’t be certain, but it’s predictable, err, and it’s obviously what’s happened to your mum . . .(A further detailed explanation followed of the role of hormone replacement therapy, its benefits and risks, including numericalexpressions of risk, with the woman saying little until the doctor says:)Effectively the choice is yours.Patient: Right.Doctor: Err, it doesn’t suit everybody, really the only way to know if it’s going to suit you is to try for a time.Patient: Mmmh, do you really think that I need to be on it then?Doctor: Err.Patient: Do you think that if I don’t go on it I’m going to end up more with osteoporosis.Doctor: I think you’ll continue, you will continue to lose bone, it’s quite a difficult decision to take because you’re decision now, really you’retrying to take a decision now to improve your health when you’re in your 70s and 80s with osteoporosis.(The doctor explains further. The consultation ends with the doctor saying:) Anyway the choice is yours.Patient: All right thank you for your time. (Bone clinic, consultation 001) Extract 2:Woman mentions tiredness (The doctor inquires about menopausal symptoms and after some discussion the woman asks:) With HRT, can’t you only go on that for so long, and then they take you off? Am I wrong?Doctor: What happens with HRT is . . .(The woman laughs)Doctor: Right HRT . . . whilst you’ve got your own hormone you don’t need HRT, so your bones are being protected by your naturalhormone. Um, and HRT you get benefit from for your bones, for your heart point of view, from lots of different points of view. Now thelonger you’re on HRT from the bones point of view, the better. The problem is the longer you’re on it from your breast point of view,people worry about the increase in breast cancer.Patient: Mmm.Doctor: And so what they try . . . it’s a balance of risks. So you take everybody individually. So somebody who has, a, a, wor . . . a concernabout breasts, maybe family history of breast cancer or something like that, you may be a bit more cautious on that side, but if somebody’sgot a dreadful history of thinning of the bones, and osteoporosis you sort of have to weigh that up, don’t you. So you’d say “oh well perhapsyou . . .” you know. So everybody’s individual, you weigh it up individually. The basic thing is that if you’re on HRT for, say, 10 years, say,there is definitely an increase in risk of breast cancer. At five years, less so. Seven-and-a-half, it . . . what . . . up to five years is thought to befairly safe. So what . . . that, that’s where this business about “you can only be on it a certain length of time.”Patient: Mmm.Doctor: I’ve actually got ladies that have been on it 15 years. And are very very happy with it. I mean they wouldn’t stop it because it makes .. . it keeps them well.Patient: Mmm.Doctor: So you, what you do is you balance up that good you’re getting from it, with the downside.(The consultation continues, returning to consideration of the woman’s tiredness. Hormone replacement therapy is not prescribed, but the woman is asked to think about it as a possibility for the future.) (General practice, consultation 025) Papers page4of7  BMJ  Online First bmj.com
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