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Lecture 1 Recognising and capturing clinical uncertainty

Lecture 1 Recognising and capturing clinical uncertainty. Foreground and background knowledge. foreground knowledge. Background knowledge. Expertise and decision making. clarification. Clinical uncertainty Clinical judgement Clinical decision making Evidence based decision making.

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Lecture 1 Recognising and capturing clinical uncertainty

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  1. Lecture 1Recognising and capturing clinical uncertainty Dr Carl Thompson, University of York

  2. Foreground and background knowledge foreground knowledge Background knowledge Expertise and decision making Dr Carl Thompson, University of York

  3. clarification • Clinical uncertainty • Clinical judgement • Clinical decision making • Evidence based decision making Dr Carl Thompson, University of York

  4. Clinical uncertainty • Not certainly knowing or known • Sources • Defining a disease • Making a diagnosis • Selecting an intervention • Observing outcomes • Assessing patient preferences • Combing information in a decision Dr Carl Thompson, University of York

  5. Quantifying Uncertainty • True state of the patient cannot be directly observed • Clinician must use imperfect external cues • Probability as a language for expressing uncertainty Dr Carl Thompson, University of York

  6. Probability Fundamentals • Strength of belief • A number between 0 and1 that expresses an opinion about the likelihood of an event • Probability of an event that is certain to occur is 1 • Probability of an event that is certain to NOT occur is 0 Dr Carl Thompson, University of York

  7. Types of probability Dr Carl Thompson, University of York

  8. Components of Probability Estimates • Personal experience • Published experience - evidence • Attributes of the patient Dr Carl Thompson, University of York

  9. Clinical decision and judgement • Clinical judgement • Assessment of alternatives • Clinical decision • Choosing between alternatives (Dowie 1988) Dr Carl Thompson, University of York

  10. The decisions clinicians make. • Diagnosis and test ordering (Dx) • Treatment (Rx) • Targeting • Timing • referral • Communicating (risks and benefit info) • Seeking more information • S.D.O. (service delivery and organisation) Dr Carl Thompson, University of York

  11. Clinical uncertainty – the good news • Aeschylus – ‘hope comes from the lack of certainty of fate’ • Complete certainty = lack of hope • Examination results predicted life success (100% accurately) • Learning at age 12 that you possess the Alzheimer’s gene • Adaptation to Huntington’s and HIV status Dr Carl Thompson, University of York

  12. Asking questions • Background questions: • General knowledge about a disorder • A root (who, what, when, how, and why) a verb • A disorder or aspect of a disorder • E.g. ‘what causes angina?’ Dr Carl Thompson, University of York

  13. Foreground questions P.I.C.O. • Specific knowledge about management of people with a disorder • Population: the people who are on the receiving end of your judgement and choices • Intervention: that which you are thinking of doing to (with?) them • Counter intervention: the other choices – nb. sometimes not in a question when no choice • Outcome: what do you want see happen (or not happen) as a result of your choice? Dr Carl Thompson, University of York

  14. Population - Can Include: • Disease or condition • Sex, age, race, socio-economic setting • Stage of disease, care setting Dr Carl Thompson, University of York

  15. Interventions - Can Include: • General or specific interventions • treatment options or specific drug, risk factors or specific cause • Level of intervention • Frequency/dosage • Stage of intervention • prevention, secondary prevention, early, advanced • Delivery of intervention • setting, professional group, self-medication Dr Carl Thompson, University of York

  16. Comparisons With The Intervention - Can Include: • Standard practice • Gold standard intervention • Placebo • Other specific comparisons Dr Carl Thompson, University of York

  17. Outcomes - Can Include: • Clinical Outcomes • mortality, reduction of symptoms, adverse effects • Provider-oriented Outcomes • cost-effectiveness, benefits to service • Patient-oriented Outcomes • QoL, satisfaction, acceptance Dr Carl Thompson, University of York

  18. Why bother with PICO? • Helps focus scarce learning time on relevant evidence for patient need • Helps focus scarce learning time on evidence that addressed your knowledge needs • Suggests high yield search strategies • Suggest the form useful answers might take • Aid referrals by clearly communicating needs • As a basis for teaching others (clarity in communication) • Leads to answers  increases your motivation Dr Carl Thompson, University of York

  19. Some examples • Is sucrose a safe and effective analgesic during painful procedures in newborns? • Do prenatal and postnatal home visits by nurses have long term effects on maternal and child outcomes? • Do transparent polyurethane dressings reduce dislodgement, phlebitis, and “tissuing” of peripheral IV catheters compared to gauze? • Is exposure to parental tobacco smoke associated with an increased risk of asthma in school age children? Dr Carl Thompson, University of York

  20. Your go! Dr Carl Thompson, University of York

  21. Intro to a Search Strategy: • Start with a clear answerable question • Break the question down into concepts • Search each concept separately • (use indexing terms, other indexing features, textwords] • Combine terms • Limit results Dr Carl Thompson, University of York

  22. Searching For Individual Concepts: • Indexing terms (thesaurus terms, subject headings) • eg. MeSH • mapping • Textwords • synonyms • alternative spellings and word endings • truncation (usually $ or *) eg. manag$ • proximity operators [usually adj# or near#] eg. home adj3 help • exact phrase [usually “ # ”] eg. “clinical governance” Dr Carl Thompson, University of York

  23. Combining concepts • AND - Creates a smaller set; both concepts must be present. In this case the result set is the records which contain both the smoking and counselling concepts. Result set Smoking Counselling Dr Carl Thompson, University of York

  24. Combining concepts • OR - Creates a larger set; any or all concepts must be present. Used to link similar concepts. In this case the result set is the records which contain both the psychotherapy and counselling concepts (all the blue area) Psychotherapy Counselling Dr Carl Thompson, University of York

  25. Combining concepts • NOT - Excludes a concept. Used to remove specific concepts. In this case the result set is the records which contain tobacco but not those which also contain snuff (yellow hatched area). Use with care because it can have unexpected results. Snuff Tobacco Dr Carl Thompson, University of York

  26. Example search, using MEDLINE subject headings #1 substance use disorders/ #2 exp substance dependence/ #3 drug adj addiction #4 or/1-3 #5 exp child/ #6 teenager? or adolescent? or young adj people #7 or/5-6 #8 exp health promotion/ #9 prevent? adj (campaign? or program? or activit?) #10 or/8-9 #11 4 and 7 and 10 Dr Carl Thompson, University of York

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