MICHAEL TRINGALE'S DISSERTATION
The practice of evidence-based medicine (EBM) has long called for health care professionals (HCPs) to consider patient values and preferences alongside the best available research and clinical expertise for individual patients. However, this critical topic has been almost completely ignored and is underrepresented in EBM research. This may be because understanding patient values and preferences, and what HCPs think of them, tends to be more reliant on qualitative evidence, a level of evidence that does not (yet) appear in the EBM hierarchy. (See Michael's blog post about the importance of qualitative research in EBM).
Michael thesis, "Incorporating patient values and preferences in health care for adults with noncommunicable diseases: A systematic review of qualitative evidence.” , sought to understand and address this gap in the literature with a systematic review of qualitative evidence examining how HCPs actually approach values integration in the care they provide.
A total of 35 records involving 1,006 HCP participants were included and Michael found 146 specific approaches to incorporating values: behaviors like “eliciting patient preferences,” “advocating for the patient,” “respecting privacy,” “shared decision making,” “active listening,” “cultural sensitivity,” “seeing the patient as a partner,” “showing compassion,” “allowing time to process emotions,” “leaving time for questions,” “celebrating successes,” “inviting patient participation,” “sharing evidence,” “using common language,” and many others. After an in-depth analysis, all of the approaches were summarized into four primary themes:
- Approaches of Concern referring to HCP behaviors that demonstrate concern for the patient as a person and concern for diseases and their effects.
- Approaches of Competence referring to HCP competencies at addressing diseases, understanding research evidence, and managing patient outcomes.
- Approaches of Communication referring to how the HCP communicates with the patient as a partner, shares information and evidence, and manages patient engagement.
- Approaches of Congruence referring to how the HCP tailors care for individual patients and maintains flexibility and balance between patient values and preferences, research evidence, and clinical expertise.
These themes provide a novel framework for understanding and addressing the integration of patient values and preferences in health care, and Michael hopes to continue exploring this more in future research.
Upon reflection of the course, Michael concluded, "I highly encourage other students in the MSc EBHC program to join me in researching issues related to integrating patient values and preferences; it represents an area in need of systematic exploration and it is of critical importance to modern health care.".
Michael also gives thanks to his supervisors, Dr Carl Heneghan and Dr Anne-Marie Boylan for their guidance and support, as well as his fellow MSc student, Genia Stephen, for her role as secondary screener.
CLAIRE DUDDY'S DISSERTATION
Many research studies show us that some doctors order more laboratory tests (like blood tests) than others, and that laboratory testing has been increasing for many years.
Claire's thesis, "Explaining variation in laboratory test ordering in primary care: a realist review.", was designed to explore the reasons that doctors order tests, to help better understand why different doctors make different decisions, and why testing is increasing.
The project was a realist review, an approach to research that involves gathering together research studies and other documents that have already been published, to see what they can tell us when they are looked at together. Throughout the project, Clare spoke to doctors, patients and policymakers to learn about their real-life experience of test ordering, help to focus our search for information, and make sure findings made sense. Data gathered included 145 documents in this review altogether, and were read and analysed to better understand how and why doctors make decisions to order laboratory tests.
It was found that doctors use tests for many different reasons. Doctors may not consider laboratory tests to be important or expensive enough to worry about too much, and so may habitually order tests that are not strictly medically necessary. They may prioritise efficiency and pragmatism over thoroughness in making decisions about their use. For example, doctors may routinely order tests as a one-size-fits-all approach, or to try to manage or improve their relationships with patients. Cultural beliefs, performance targets, and the design of computer systems may mean that ordering tests is easier than not ordering them. The more tests are used, the more patients and doctors may come to rely on them, so that testing continues to increase.
Changing test ordering behaviour might depend on changing doctors’ test ordering habits, but it is important to recognise that encouraging doctors to think carefully before ordering tests requires additional time and mental energy, which may be better placed elsewhere. Future interventions that aim to change test ordering behaviour and evaluations of these interventions should take real-world practice into account – it is important to recognise that making changes to test ordering systems may not change perceptions of laboratory tests and encouraging thoroughness in decision making in this area of practice could have unintended consequences elsewhere. The findings of the review have been published and are available (open access) here: https://bjgpopen.org/content/5/2/bjgpopen20X101146.
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