Evidence-based medicine in general practice: a hindrance to optimal medical care?

The Craft of Generalism clinical skills and attitudes for whole person care

RATIONALE, AIMS AND OBJECTIVES

Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism.

METHODS

The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research.

RESULTS

The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent.

CONCLUSIONS

Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.

An empirical study of patient participation in guideline development: exploring the potential for articulating patient knowledge in evidence-based epistemic settings

BACKGROUND

Patient participation on both the individual and the collective level attracts broad attention from policy makers and researchers. Participation is expected to make decision making more democratic and increase the quality of decisions, but empirical evidence for this remains wanting.

OBJECTIVE

To study why problems arise in participation practice and to think critically about the consequence for future participation practices. We contribute to this discussion by looking at patient participation in guideline development.

METHODS

Dutch guidelines (n = 62) were analysed using an extended version of the AGREE instrument. In addition, semi-structured interviews were conducted with actors involved in guideline development (n = 25).

RESULTS

The guidelines analysed generally scored low on the item of patient participation. The interviews provided us with important information on why this is the case. Although some respondents point out the added value of participation, many report on difficulties in the participation practice. Patient experiences sit uncomfortably with the EBM structure of guideline development. Moreover, patients who develop epistemic credibility needed to participate in evidence-based guideline development lose credibility as representatives for 'true' patients.

DISCUSSION AND CONCLUSIONS

We conclude that other options may increase the quality of care for patients by paying attention to their (individual) experiences. It will mean that patients are not present at every decision-making table in health care, which may produce a more elegant version of democratic patienthood; a version that neither produces tokenistic practices of direct participation nor that denies patients the chance to contribute to matters where this may be truly meaningful.

The effect of preventive consultations on young adults with psychosocial problems: a randomized trial

Patients with many problems often face difficulties in modifying their behavior as desired. Uncovered basic needs may be an important barrier. This research tests the effect of patient-centered consultations for 20- to 44-year-old patients with multiple psychosocial and lifestyle problems. We focus on resources and barriers for obtaining self-chosen goals within life circumstances and lifestyle. At 28 general practitioners, 2056 patients aged 20-44 years were screened with a 33-item problem-score on resources, network, lifestyle and social conditions. The 30% who had most problems were invited to complete a more comprehensive questionnaire at home. Intervention was preventive consultation with a 3-month follow-up. A total of 495 patients were randomized. One-year questionnaire follow-up showed significant improvement in Short Form Health-related Quality of Life Mental (MCS-SF12) in the intervention group (7.3) compared with the control group (3.0); the difference was 4.3 (95% confidence interval 1.6-7.0, P = 0.002). The number of problems was reduced significantly more in the intervention than in the control group (1.8 versus 0.8, P = 0.03). Preventive consultation focusing on resources and barriers to self-chosen goals may improve MCS-SF12 and decrease the number of problems in patients with many psychosocial and lifestyle problems. This may be an indicator of improved specific self-efficacy and a key to lifestyle changes.

When is knowledge ripe for primary care? An exploratory study on the meaning of evidence

The objectives of this study were to explore the meaning of scientific evidence as it is understood by primary care physicians. Individual interviews were conducted with actors chosen for their roles in the production and use of knowledge: 22 family physicians, 13 specialist physicians, and 6 researchers. Two situations served as points of reference for these discussions: screening for genetic breast cancer and treatment of hypertension. The results suggest that there may be a misunderstanding between the producers of knowledge and primary care practitioners with respect to what constitutes "evidence"--knowledge ready for integration into the clinical practice of primary care. These potential differences go beyond the issues of how information is disseminated. Rather, many of the questions raised by family physicians concern how knowledge is developed. In the interests of fostering better dissemination of new knowledge and encouraging its adoption, new links should be created between knowledge "producers" and potential users.

Use of quality improvement methods in Finnish health centres in 1998 and 2003

OBJECTIVE

To evaluate how widely quality improvement methods are used in Finnish primary health centres and how the use has changed over five years.

DESIGN

Two national cross-sectional postal enquiries.

SETTING AND SUBJECTS

The questionnaire in 1998 was sent to every other physician graduated during the years 1977-1986, and the questionnaire in 2003 to every other physician graduated during the years 1982-1991. The response rates were 73.9% and 62.2%. The answers of primary healthcare physicians (n = 503 vs. 344) were analysed.

MAIN OUTCOME MEASURES

The availability of 13 quality improvement methods was solicited. The change over five years was analysed.

RESULTS

Opportunity to obtain continuing medical education (CME), in-service training, meetings, opportunity to consult a colleague in own speciality, and agreed guidelines on how a certain problem should be solved were highly reported both in 1998 and 2003. The biggest improvement (16.8%) concerned clinical guidelines. There was also progress with regard to quality improvement manuals at the place of work, opportunity to consult a colleague in another speciality, and computer-assisted monitoring of own work.

CONCLUSION

Many quality improvement methods were highly reported in both 1998 and 2003 in Finnish health centres. The biggest positive change concerns clinical guidelines.

GPs' thoughts on prescribing medication and evidence-based knowledge: the benefit aspect is a strong motivator. A descriptive focus group study

OBJECTIVE

To describe GPs' thoughts of prescribing medication and evidence-based knowledge (EBM) concerning drug therapy.

DESIGN

Tape-recorded focus-group interviews transcribed verbatim and analysed using qualitative methods.

SETTING

GPs from the south-eastern part of Västra Götaland, Sweden.

SUBJECTS

A total of 16 GPs out of 178 from the south-eastern part of the region strategically chosen to represent urban and rural, male and female, long and short GP experience.

METHODS

Transcripts were analysed using a descriptive qualitative method.

RESULTS

The categories were: benefits, time and space, and expert knowledge. The benefit was a merge of positive elements, all aspects of the GPs' tasks. Time and space were limitations for GPs' tasks. EBM as a constituent of expert knowledge should be more customer adjusted to be able to be used in practice. Benefit was the most important category, existing in every decision-making situation for the GP. The core category was prompt and pragmatic benefit, which was the utmost benefit.

CONCLUSION

GPs' thoughts on evidence-based medicine and prescribing medication were highly related to reflecting on benefit and results. The interviews indicated that prompt and pragmatic benefit is important for comprehending their thoughts.

Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice. A descriptive epidemiological study

OBJECTIVE

Our first objective is to describe total, age- and gender-specific prevalences of subjects in a well-defined population for whom medical follow-up is indicated due to unfavourably high blood pressure and/or cholesterol levels, as defined by the 2003 European guidelines on cardiovascular disease prevention in clinical practice. Our second objective is to highlight scientific questions and ethical dilemmas relating to implementation of the guidelines.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional population study comprising 62104 adult Norwegians aged 20-79 years who participated in The Nord-Tröndelag Health Study 1995--97.

MAIN OUTCOME MEASURES

Total, age- and gender-specific point prevalences of individuals with total cholesterol > or =5 mmol/l and/or systolic blood pressure > or =140 mmHg and/or diastolic blood pressure > or =90 mmHg, or taking antihypertensive medication.

MAIN RESULTS

In total, 76% of individuals aged 20-79 years have an "unfavourable" cardiovascular disease risk profile, according to guideline definitions. The point prevalence of individuals with cholesterol and/or blood pressure above the recommended cut-off points increases with age. By age 24, the prevalence reaches 50%. By age 49, it reaches 90%. Men below 50 years of age have higher combined risk prevalence than women.

CONCLUSIONS AND IMPLICATIONS

Implementation of the 2003 European guidelines on CVD prevention would label a large majority of Norwegian adults as having unfavourably high cholesterol and/or blood pressure levels. The current biomedical standards appear to invalidate demographic health statistics. The theoretical basis on which the guidelines rest should thereby be scrutinized with regard to scientific methodology and consistency. Important ethical dilemmas arise at the point of guideline implementation, relating to risk labelling and medicalization, as well as resource allocation and sustainability within the healthcare system.