In and Out of Context
http://www.100md.com
《家庭医学史册》
THE IMPORTANCE OF CONTEXT
One of the functions of the Annals online discussion is to provide context for interpreting and applying the results of published articles. Many of the online comments since the last issue make a larger point. Context matters. It is important for interpreting and applying findings from the perspectives of patients,1,2 clinicians,1,3–7 students,8 and different settings.9 The additional context of knowledge from other studies,10–14 disciplines,15,16 or perspectives14,17–20 can totally reframe the study question or understanding of the meaning of the findings.
Out of Context
Also striking in the online discussion are the comments that are worth reading even in isolation from the well-reasoned arguments that surround them. You can sample these below, and in the references you can find the link to put these excerpts back in the context provided by the authors.
The first comment is a wake-up call for those who think that by increasing the application of evidence-based medicine automatically, we will improve the quality of care. The author is writing from the perspective of the patient, but as a physician, her insight also is grounded in professional knowledge of what constitutes good medical care. If we expect systems and incentives supporting evidence-based medicine to improve our care of whole people, we need to generate and value additional kinds of evidence that greatly expand what currently is known. We need to value and support different ways of knowing that go beyond understanding the causes or treatment of individual diseases.21 We must ensure that our evidence base includes but transcends measures of central tendency in selected groups of patients, to include the effects of illness and treatment in the context of individuals and families and communities.
"My physician uses my semiannual visit to be sure I have had my mammogram, flu shot, stool occult blood, routine lab work, etc, things which could be done by a computer in the waiting room, or the assistant who took my blood pressure. She does not question me about my home blood pressure monitoring, my drug side effects, changes in my health, etc. This is not good medical care, yet very likely she is being ‘graded’ on these mechanistic things, with the assumption that ‘good medical care’ will follow. So far, it has not!"1
"Academic medicine and frontline medicine have never been farther apart."22
"The Beasley et al study showed that physicians working for independent practices had a better quality work life and were also more satisfied with their amount of family time. Perhaps, there is more of a connection between these 2 ‘lives’ than some physicians realize."10
"Medical students are becoming more and more aware of the ethical problems that arise when we, as health care providers, interact with drug company reps and their propaganda. AMSA, the biggest medical student group in the USA, has an official policy to be free of drug company money and advertisements."8
"Since my awareness has been raised on this issue [health literacy], I’ve been doing an instant assessment by reading the portion of the chart that has been handwritten by the patient. Coarse printing and misspellings are a tip-off that the patient may have literacy issues, and I change my approach accordingly."7
"We found that compar trieval systems improved correct answers to clinical scenarios by 21%.... Interestingly, experienced specialist nurses, who performed poorly unaided when compared with their medical colleagues, improved their performance to equal the doctors once they had access to an online evidence system."11
"Suicidal ideation in primary care patients is as transient as depression often is, and it is a reflection of the wisdom of the study physicians that not only do they often use watchful waiting for many patients who are mildly depressed, they do the same with transient suicidal ideation."5
"These data speak to the importance of inquiring about suicidality whenever patients are emotionally distressed, whether or not they are depressed."4
"You are out of the loop."23
"[Patients] also seem to be saying that they expect caring communication and kindness and not just technically proficient service."17
"While there are many studies about the relationships between primary care physicians and their patients (4,920) there are far fewer dealing with nurse-patient relationships (523) or receptionist-patient relationships (52 if you include any article about receptionist roles, only 8 if you limit to a focus on professional-provider relationships) in primary care. More work is required in this area, particularly as there is a move towards models of care based on multidisciplinary group practices and away from traditional models based on the relationship between a patient and a single physician."18
"Ultimately, this is why we physicians strive so hard for excellence. Excellence is personal, not impersonal, because it derives from the caring relationship. And, this is why the caring relationship is truly the central tenet of doctoring."14
"Dealing with very sick and dying people we find that there are often too many things to be concerned about without having to negotiate elements of clinical intervention. In many ways therefore a paternalistic approach (or perhaps more accurately a parental approach) is called for and accepted."19
"The adverse evaluation of consumerism offered may also be hasty. While the early literature in sociology presented health care consumers in a conflict oriented perspective, recent conceptualizations regard proactive health care consumers as building collaborations with physicians."15
"The 40 some million Americans with no health insurance and who use the emergency room for their care will never experience what Dr. Buetow is advocating."9
"How do we expect the abused, the hurting, and the damaged to be the ones to save themselves from monstrous power inequalities?"24
"[T]his paper shows how important it is for us to strive to make our offices places where our patients have a transforming experience."20
"Our current approaches to health care investment are too often based on slivers of targeted activity rather than more comprehensive assessment and phased-in actions. Instead, we need a ‘systematic approach’ to critically analyzing health care broadly, including the ‘system’ features that are essential to ensuring that care is timely and appropriate. Without the bigger picture in focus, tradeoffs that are made are hidden – except for the occasional article, like this one, that illuminates some of them."25
REFERENCES
Buchanan SF. Tests vs medical care.
Killip S. Commentary.
King DK. Reaction and questions for discussion re: the NVS Health Literacy Assessment.
Acheson LS. Suicidality and comorbid psychiatric conditions.
Schwenk TL. Is detecting suicidal ideation good?.
Miron E. Another example – pap smears.
Hess DW. Re: Some questions about screening for literacy.
Fleg A. Thanks - speaking the truth on an issue/realm that sorely needs it!.
Bruhn JG. Going beyond the coprovision of care.
DeVoe JE. Differing views on what contributes to physician satisfaction.
Westbrook JI. The outcomes when clinicians use online evidence systems.
Pluye P. A landmark trial despite the lack of objective outcomes.
Bennett IM. Some questions about screening for literacy.
Branch WT Jr, et al. To care is to coprovide: semantics or an important difference?.
Kahana E, et al. Health care partnerships – "But Not by Prescription" .
Buchbinder SB. Physician quality of work life matters.
Aita VA. Commentary by Aita .
Green ME. Teams, trust and patient’s responses to preventable medical problems.
MacLeod R. Caring connections .
Kuzel AJ. The impact of "relationship mistakes" .
Stange KC, Miller WL, McWhinney I. Developing the knowledge base of family practice. Fam Med. 2001;33:286–297.[Medline]
Shaw JA. Public health, wealth, culture and social structure in the US of a.
O’Neill LV. Stop your tunnel vision and use common sense.
Hays L. Collusion of silence—who is responsible?
Wakefield MK. The best of times and the worst of times.(Kurt C. Stange, MD, PhD, )
One of the functions of the Annals online discussion is to provide context for interpreting and applying the results of published articles. Many of the online comments since the last issue make a larger point. Context matters. It is important for interpreting and applying findings from the perspectives of patients,1,2 clinicians,1,3–7 students,8 and different settings.9 The additional context of knowledge from other studies,10–14 disciplines,15,16 or perspectives14,17–20 can totally reframe the study question or understanding of the meaning of the findings.
Out of Context
Also striking in the online discussion are the comments that are worth reading even in isolation from the well-reasoned arguments that surround them. You can sample these below, and in the references you can find the link to put these excerpts back in the context provided by the authors.
The first comment is a wake-up call for those who think that by increasing the application of evidence-based medicine automatically, we will improve the quality of care. The author is writing from the perspective of the patient, but as a physician, her insight also is grounded in professional knowledge of what constitutes good medical care. If we expect systems and incentives supporting evidence-based medicine to improve our care of whole people, we need to generate and value additional kinds of evidence that greatly expand what currently is known. We need to value and support different ways of knowing that go beyond understanding the causes or treatment of individual diseases.21 We must ensure that our evidence base includes but transcends measures of central tendency in selected groups of patients, to include the effects of illness and treatment in the context of individuals and families and communities.
"My physician uses my semiannual visit to be sure I have had my mammogram, flu shot, stool occult blood, routine lab work, etc, things which could be done by a computer in the waiting room, or the assistant who took my blood pressure. She does not question me about my home blood pressure monitoring, my drug side effects, changes in my health, etc. This is not good medical care, yet very likely she is being ‘graded’ on these mechanistic things, with the assumption that ‘good medical care’ will follow. So far, it has not!"1
"Academic medicine and frontline medicine have never been farther apart."22
"The Beasley et al study showed that physicians working for independent practices had a better quality work life and were also more satisfied with their amount of family time. Perhaps, there is more of a connection between these 2 ‘lives’ than some physicians realize."10
"Medical students are becoming more and more aware of the ethical problems that arise when we, as health care providers, interact with drug company reps and their propaganda. AMSA, the biggest medical student group in the USA, has an official policy to be free of drug company money and advertisements."8
"Since my awareness has been raised on this issue [health literacy], I’ve been doing an instant assessment by reading the portion of the chart that has been handwritten by the patient. Coarse printing and misspellings are a tip-off that the patient may have literacy issues, and I change my approach accordingly."7
"We found that compar trieval systems improved correct answers to clinical scenarios by 21%.... Interestingly, experienced specialist nurses, who performed poorly unaided when compared with their medical colleagues, improved their performance to equal the doctors once they had access to an online evidence system."11
"Suicidal ideation in primary care patients is as transient as depression often is, and it is a reflection of the wisdom of the study physicians that not only do they often use watchful waiting for many patients who are mildly depressed, they do the same with transient suicidal ideation."5
"These data speak to the importance of inquiring about suicidality whenever patients are emotionally distressed, whether or not they are depressed."4
"You are out of the loop."23
"[Patients] also seem to be saying that they expect caring communication and kindness and not just technically proficient service."17
"While there are many studies about the relationships between primary care physicians and their patients (4,920) there are far fewer dealing with nurse-patient relationships (523) or receptionist-patient relationships (52 if you include any article about receptionist roles, only 8 if you limit to a focus on professional-provider relationships) in primary care. More work is required in this area, particularly as there is a move towards models of care based on multidisciplinary group practices and away from traditional models based on the relationship between a patient and a single physician."18
"Ultimately, this is why we physicians strive so hard for excellence. Excellence is personal, not impersonal, because it derives from the caring relationship. And, this is why the caring relationship is truly the central tenet of doctoring."14
"Dealing with very sick and dying people we find that there are often too many things to be concerned about without having to negotiate elements of clinical intervention. In many ways therefore a paternalistic approach (or perhaps more accurately a parental approach) is called for and accepted."19
"The adverse evaluation of consumerism offered may also be hasty. While the early literature in sociology presented health care consumers in a conflict oriented perspective, recent conceptualizations regard proactive health care consumers as building collaborations with physicians."15
"The 40 some million Americans with no health insurance and who use the emergency room for their care will never experience what Dr. Buetow is advocating."9
"How do we expect the abused, the hurting, and the damaged to be the ones to save themselves from monstrous power inequalities?"24
"[T]his paper shows how important it is for us to strive to make our offices places where our patients have a transforming experience."20
"Our current approaches to health care investment are too often based on slivers of targeted activity rather than more comprehensive assessment and phased-in actions. Instead, we need a ‘systematic approach’ to critically analyzing health care broadly, including the ‘system’ features that are essential to ensuring that care is timely and appropriate. Without the bigger picture in focus, tradeoffs that are made are hidden – except for the occasional article, like this one, that illuminates some of them."25
REFERENCES
Buchanan SF. Tests vs medical care.
Killip S. Commentary.
King DK. Reaction and questions for discussion re: the NVS Health Literacy Assessment.
Acheson LS. Suicidality and comorbid psychiatric conditions.
Schwenk TL. Is detecting suicidal ideation good?.
Miron E. Another example – pap smears.
Hess DW. Re: Some questions about screening for literacy.
Fleg A. Thanks - speaking the truth on an issue/realm that sorely needs it!.
Bruhn JG. Going beyond the coprovision of care.
DeVoe JE. Differing views on what contributes to physician satisfaction.
Westbrook JI. The outcomes when clinicians use online evidence systems.
Pluye P. A landmark trial despite the lack of objective outcomes.
Bennett IM. Some questions about screening for literacy.
Branch WT Jr, et al. To care is to coprovide: semantics or an important difference?.
Kahana E, et al. Health care partnerships – "But Not by Prescription" .
Buchbinder SB. Physician quality of work life matters.
Aita VA. Commentary by Aita .
Green ME. Teams, trust and patient’s responses to preventable medical problems.
MacLeod R. Caring connections .
Kuzel AJ. The impact of "relationship mistakes" .
Stange KC, Miller WL, McWhinney I. Developing the knowledge base of family practice. Fam Med. 2001;33:286–297.[Medline]
Shaw JA. Public health, wealth, culture and social structure in the US of a.
O’Neill LV. Stop your tunnel vision and use common sense.
Hays L. Collusion of silence—who is responsible?
Wakefield MK. The best of times and the worst of times.(Kurt C. Stange, MD, PhD, )