Clinical Jazz: Harmonizing Clinical Experience and Evidence-Based Medicine
This article discusses ways to reconcile perceived conflicts between evidence-based medicine (EBM) and clinical experience, highlighting the potential problems associated with relying solely on clinical experience. The authors advocate for a restructuring of the approach to clinical decision-making, creating a harmonious blend of EBM and clinical experience, akin to the improvisational style of jazz music.
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PowerPoint presentation about 'Clinical Jazz: Harmonizing Clinical Experience and Evidence-Based Medicine'. This presentation describes the topic on This article discusses ways to reconcile perceived conflicts between evidence-based medicine (EBM) and clinical experience, highlighting the potential problems associated with relying solely on clinical experience. The authors advocate for a restructuring of the approach to clinical decision-making, creating a harmonious blend of EBM and clinical experience, akin to the improvisational style of jazz music.. The key topics included in this slideshow are Clinical jazz, evidence-based medicine, clinical experience, decision-making, conflicts,. Download this presentation absolutely free.
1. Clinical Jazz Harmonizing Clinical Experience and Evidence-Based Medicine David C. Slawson, MD Allen F. Shaughnessy, PharmD Lorne A. Becker, MD Shaughnessy AF, Slawson DC, Becker L. Clinical jazz: Harmonizing clinical experience and evidence-based medicine. J Fam Pract 1998;47:425-8.
2. Objectives Perceived conflicts between EBM and clinical experience Problems associated with relying solely on clinical experience- self/experts Restructuring into harmony- clinical jazz
3. Clinical Experience The fertile ground from which ideas and hypotheses grow Major conflict: Experience doesnt jibe with research-based evidence
4. Clinical Experience Not a source of valid POEMs Multiple validity problems
5. Clinical Experience - Validity Latest bad experience bias Out of sight, out of mind he would have told me if he was having problems Nonrandom loss to follow up Dissatisfied customers go elsewhere Inability to combine outcome data for multiple patients
6. Clinical Experience - Validity Small sample size Stacking the deck: Biased allocation to treatment groups Rose-colored glasses: Biased assessment of outcomes
7. Reverse Gullibility The story of Semmelweis 1847: hand washing decreased obstetric mortality from 18% to 1.2% Virulent attacks lead to asylum commitment MDIs vs nebulizers, eye-patches, H. pylori for PUD (Barry Marshall), home glucose monitors
8. Experience: A problem of perception Moral : Clinical experience sometimes prevents seeing the right picture Now that you see it, can you try to not see it? Moral : Experience can result in ideas that are difficult to change 4 Do you see the Dalmatian in the picture? www.optillusions.com
9. Perceptions are difficult to refute Why is it so hard to believe that this is not a spiral but actually a set of concentric circles? http://www.michaelbach.de/ot/ang_frazer/index.html
10. They really are!
11. Clinical Experience Not really in competition with EBM
12. Combining EBM and Experience: Clinical Jazz Structure plus Improvisation
13. Clinical Jazz Improvisation without structure = cacophony
14. Structure without Improvisation= tedium Clinical Jazz
15. Remember The Expert Expert in diagnosis and procedures (clinical experience) Not necessarily expert in therapeutics (EBM) Case series; LOE 4 at best The best expert (YODA) combines experience with the evidence = Clinical Jazz
16. Advantages of Information Mastery A liberating structure Stable (little chance of ping-pongs) Simple rules (find the valid POEMs) Relatively non-restrictive There arent that many valid POEMs!
17. Clinical Improvisation - Opportunities Conditions with no valid POEMs e.g. Screening for prostate cancer Conditions with multiple valid POEMs e.g. Depression
18. Clinical Improvisation - Opportunities Patients whose characteristics differ from those of patients included in research studies Implementation methods for valid POEMs
19. Clinical Improvisation - Potential Sources of Inspiration Clinical Experience Colleagues Ideas Local Experts & Consultants Standard of Care DOEs Others
20. Clinical Improvisation Not a Solo Activity Including the patients perspective Working with a clinical team Working with consultants Working with partners
21. If you cant listen, you cant play jazz Wynton Marsalis
22. Valid POEMs Outcomes-Based Research Goal: Not to replace clinical judgment, but to give clinicians more information to base opinions and practices. Primum non Nocere Dualism- distinction between clinical experience and patient-oriented research is in error
23. Circle of Clinical Reasoning Patient seen in practice Outcomes Research Clinical Judgment
24. Flaws in the Circle of Reasoning Fallacy of Division : What is true of the whole must also be true of its parts Bell curve of clinical response Law of Diminishing Return, the Keflex- Reflex (How low do you need to go?)
25. Flaws in the Circle of Reasoning Fallacy of Hasty Conclusion : What is true of the parts must also be true of the whole Using evidence from clinical experience to justify a general approach to all patients, without applying the rigors of the scientific method, may result in harm
26. Flaws in the Circle of Reasoning Must consider overall effect on population (disease-specific vs all-cause mortality) PSA: may decrease deaths from prostate CA Overall may harm more than help (quantity or quality of life) Colon/breast CA- Less CA deaths, more CV deaths/year compared with control 2/10,000/year fewer CA deaths 2/10,000/year more CVD deaths Bill and Jane die sooner so Frank and Judy live longer Patient-specific vs population-based screening Need for personal decision analysis using utilities Wisdom vs knowledge vs information
27. Why is Medicine Here? Goals of medicine: Relieve/prevent suffering Maintain/provide hope Prevent, treat, or cure disease The science of medicine: knowing the best way to prevent, treat, or cure disease EBM can address this aspect The art of medicine: Determining, using intuition, experience, and judgment, what patients need the most Clinical jazz = science + art
28. Mundus Vult Decipi- The world wishes to be deceived People would rather be deceived than have the truth create anxiety. -Caleb Carr, Killing Time
29. The only sure foundations of medicine are an intimate knowledge of the human body and observations on the effects of medicinal substances on that body -Thomas Jefferson
30. Americas two greatest gifts to the world are jazz and Medline. --Richard Smith, BMJ 2001
31. The Yin and Yang of Medicine (Start music) Rigid enforcement of outcomes-based guidelines just as misguided as foregoing results of patient-oriented research The seeming opposites of medical practice, clinical science and clinical experience, are inseparable Structure with improvisation = true art
32. If we shadows have offended, Think but this, and all is mended, That you have but slumbered here, While these visions did appear. And this weak and idle theme, No more yielding but a dream, Gentles, do not reprehend. If you pardon, we will mend . . . . So good(bye) unto you all. William Shakespeare- A Midsummer Nights Dream