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Rothberg et al. (2010) Patients’ & Cardiologists’ Perceptions of the Beneﬁts of PCI for Stable Coronary Disease, Ann Intern Med Available at: http://bit.ly/qA2xV7 Hosted by Fi Douglas
twitjournalclub Good evening everyone. Welcome to this week's #TwitJC, which will be looking at Perceptions of the Benefit of PCI. -8:01 PM amcunningham RT @twitjournalclub: Good evening everyone. Welcome to this week's #TwitJC, which will be looking at Perceptions of the Benefit of PCI. -8:02 PM twitjournalclub The link to the paper is here: http://t.co/8ioTC7N, and the introduction is here: http://t.co/jy93Tyf. #TwitJC -8:03 PM PaedsSHO I'm not stopping long; need to go to work! Pizza eaten, beer sadly unopened. #twitjc 8:03 PM dean_jenkins Looking at perceptions of benefit ... and how they should be measured. #twitjc -8:03 PM twitjournalclub You can also find the discussion points for the evening at http://t.co/BHmlQu9 #TwitJC -8:03 PM amcunningham @ePatientDave @glynelwyn have you seen that SDM is being discussed now in Twitter journal club? http://t.co/eERDpyK #TwitJC -8:03 PM dean_jenkins #1 the single centre design is a huge limitation. The way they 'measured' belief is also a limitation to this study. #twitjc -8:04 PM amitns Hi, GP registrar. A very interesting topic for #TwitJC -8:04 PM twitjournalclub As usual, let's begin with introductions... Tweeting behind this account this evening is myself (@fidouglas). #TwitJC -8:04 PM DrDLittle Evening, i'm Dave, Radiology Trainee (from next week). Missed the last few #Twitjc -8:05 PM dean_jenkins RT @amcunningham: @ePatientDave @glynelwyn have you seen that SDM is being discussed now Twitter journal club? http://t.co/eERDpyK #twitjc -8:05 PM silv24 Hi all, Natalie, currently an F1 in gastroenterology (last full week of being an F1!!) #twitjc 8:05 PM northern_doctor I'm Mark - Geris SpR and Teaching Research Fellow in North East #twitjc -8:06 PM PaedsSHO David, ST1 in paeds. About to depart for a night shift! #twitjc -8:06 PM dean_jenkins Dean - Consultant Physician who has taken a career side-track into e-learning with BMJ Group. #twitjc -8:06 PM thefourthcraw @twitjournalclub Mike, Paeds SpR in East Midlands #twitjc -8:06 PM amcunningham @dean_jenkins you're way ahead! #TwitJC -8:06 PM
PHTwitJC I'm Kate, first time on #TwitJC. I am a Brum (UK) based academic in health but a non medic (background in sociology, policy, etc.) -8:06 PM amcunningham @twitjournalclub Anne Marie - GP in South Wales... Hoping to join in #TwitJC 8:07 PM yazman89 Medical student. Will only be observing discussion. Haven't had time to read the paper with exams starting in 2 days! #TwitJC -8:07 PM dean_jenkins @amcunningham sorry ... I get so excited at these things. :-) #twitjc -8:07 PM disabledmedic Hey, I'm Flo, a 4th year med student in Scotland #twitjc -8:08 PM PHTwitJC I should be tweeting as @KateT_Health my real person account! Also it's 'bedtime hour' so will be flitting btw kids and screen #TwitJC -8:08 PM iamdoctord Richard, CT2 in medicine, waiting to be FTSTA3 Nephrology in a fortnight #twitjc 8:09 PM dean_jenkins Dinner and wine time here in Cornwall so might disappear too. #twitjc -8:09 PM northern_doctor Agree! RT @dean_jenkins: Single centre design is huge limitation. The way they measured belief is also a limitation. #twitjc -8:11 PM DrDLittle Single centre is an issue, why not expand, surely not that difficult but potentially much more valid #Twitjc -8:11 PM PHTwitJC also in process of getting a 'public health' /health journal club up inspired by #TwitJC , w. @carotomes - sounds like TwitJC inspired many! -8:12 PM twitjournalclub @dean_jenkins But you are only asking ten cardiologists who are actually performing PCI. That's a *very* small number. #twitjc -8:12 PM silv24 Interesting study but small numbers of patients and clinicians which is an issue #twitjc -8:12 PM dean_jenkins Doh! I mean numbers are important of course but what you ask them (and how) is even more important. #twitjc -8:12 PM northern_doctor Agree with @dean_jenkins - absolute number less important than how questions were asked. Single centre limits interpretation. #twitjc -8:12 PM iamdoctord Single centre studies may mean reduced inter-operator variability that may be present in a multi-centre study #twitjc -8:12 PM disabledmedic And I wondered about money / insurance issues - it would have been interesting to compare to an NHS setting #twitjc -8:13 PM PaedsSHO Single-centre is a big issue for me. 10 cardiologists doesn't seem like many. #twitjc -8:13 PM northern_doctor As an aside, I think the authors should be congratulated for finding ANY cardiologists who agree with each other ;-) #twitjc -8:13 PM DrDLittle The fact that all clinicians are in same centre suggests they might have similar thoughts and ideas #Twitjc -8:13 PM twitjournalclub @dean_jenkins Did you find a copy of the questionnaire that was given to the cardiologists? #twitjc -8:13 PM silv24 Surely it could have been expanded, different populations in different areas and a larger number of clinicians! #twitjc -8:13 PM
dean_jenkins Numbers aren't everything. This is a 'hypothesis-generating' paper. #twitjc -8:13 PM dean_jenkins Yes I got the questionnaire #twitjc -8:14 PM dean_jenkins All the appendices to the paper are available http://www.annals.org/content/153/5/307/suppl/DC1 #twitjc -8:14 PM amcunningham @PaedsSHO so you think these 10 might not be representative? Is that important? @twitjournalclub #TwitJC -8:14 PM iamdoctord 10 cardiologists is hardly representative of the cardiology population, and I concur with @DrDLittle 's last tweet #twitjc -8:14 PM northern_doctor But yes, a sample of 10 is a very small number in terms of the strength of what the paper was trying to say #twitjc -8:14 PM PaedsSHO What she said @silv24Surely it could have been expanded, different populations in different areas and a larger number of clinicians! #twitjc -8:14 PM twitjournalclub @dean_jenkins Have you got a link to it? Would be interesting to see... #twitjc 8:14 PM silv24 @dean_jenkins but wider range of views, and certainly more clinicians, mgiht have been interesting #twitjc -8:14 PM Abe702 isnt it a simple fact that a multicentre trial is better than a single centre trial? #twitjc -8:15 PM amcunningham @dean_jenkins I agree! The issue is mismatch in understanding not numbers per se #TwitJC -8:15 PM dean_jenkins @silv24 agree wider range of views (and more open interviewing) would have been useful. That could follow though ... #twitjc -8:15 PM fidouglas Presumably all cardiologists at same centre attend similar meetings/conferences. Exposed to the same information/practices? #twitjc -8:16 PM dean_jenkins @amcunningham we agree? OMG. Something must be wrong. :-) #twitjc -8:16 PM PaedsSHO @amcunningham Perhaps not representative of the consultant body as a whole. Colleagues likely to have similar ideas? #twitjc -8:16 PM amcunningham @silv24 why would wider range have made more interesting? Point is mismatch over individual patient #TwitJC @dean_jenkins -8:16 PM northern_doctor @fidouglas You'd be amazed how many different interpretations of the data there are, and how practice differs between centres #twitjc -8:17 PM Buzzmf87 Partially agree with @PaedsSHO but number of centres probably more important. And how the questions were asked! #twitjc -8:17 PM disabledmedic Is there the potential that all of them could have received the same misinformation from someone not the cardiologist? #twitjc -8:17 PM twitjournalclub How does the single-centre design affect our ability to interpret and apply this paper to other settings? #twitjc -8:18 PM dean_jenkins "Wider" as in outside the one facility. #twitjc -8:18 PM northern_doctor Most docs have their own approach to applying trial data to individual patients. Some more aggressive with treatments than others. #twitjc -8:18 PM
iamdoctord Interpretation of data may lead to differing practice per individual patient... #twitjc 8:18 PM PHTwitJC agree stats less concern than poss reflection of working practices of partic unit; custom, prac, expectations, consent procedures #TwitJC -8:18 PM silv24 @amcunningham the point is mismatch but practice varies between centres and think it would have been interesting to know #twitjc -8:18 PM dean_jenkins A single centre design risks bias. The culture at the hospital may have been such that patients were left ill-informed. #twitjc -8:18 PM GabrielScally #twitjc You cant say MC is automatically better than SC. Need to study the research hypothesis first. -8:19 PM northern_doctor @disabledmedic Yes. Good point. #twitjc -8:19 PM DrDLittle Have to be very careful applying the same conclusions to other centres #Twitjc -8:19 PM silv24 MT @dean_jenkins: A single centre design risks bias. The culture at the hospital may have been that patients were left ill-informed. #twitjc -8:19 PM twitjournalclub Second topic: #twitjc -8:20 PM GabrielScally #twitjc and a finding about the culture of that hospital is important! -8:20 PM PaedsSHO Agreed @DrDLittle: Have to be very careful applying the same conclusions to other centres #Twitjc -8:20 PM twitjournalclub If most patients spoke to their doctor for at least 5 minutes about PCI, why did 88% still believe it would reduce their risk of MI? #twitjc -8:20 PM northern_doctor In general, I think it's best practice for one of the procedural team to take consent, rather than delegate the task #twitjc -8:20 PM dean_jenkins Have you seen the consent form used in the study (and at the hospital)? Would you use it in your cath lab? #twitjc -8:20 PM iamdoctord '@dean_jenkins: ...patients were left ill-informed.' I think such a culture exists in every hospital... #twitjc -8:20 PM northern_doctor Big question - lots of variables! RT @twitjournalclub: Why did 88% still believe it would reduce their risk of MI? #twitjc -8:21 PM dean_jenkins #2 we know nothing of the conversations patients had during the consent procedure. Would have been good qualitative traingulation. #twitjc -8:21 PM Abe702 well we dont know what they were spoken to about for 5 minutes #twitjc -8:21 PM dean_jenkins @iamdoctord :-) #twitjc -8:21 PM GabrielScally #twitjc Did every clinician speak from the same script? If not we should not be surprised that they understood things differently. -8:22 PM northern_doctor Also interesting to note that they excluded non-English speakers. Wonder how that might have affected the results! #twitjc -8:22 PM dean_jenkins The consent form should have been more explicit about the benefits (or not) of PCI. #twitjc -8:22 PM disabledmedic The discussion points out might be self-selecting group - those who know better less likely to go for procedure #twitjc -8:22 PM
DrDLittle Patients often don't understand this sort of idea, impossible to explain properly in 5 mins! #Twitjc -8:22 PM iamdoctord Did the interventionist's bias (charm, persuasion) influence the patients? #twitjc -8:22 PM PHTwitJC @dean_jenkins fr REC perspective, consent form v. non-specific re actual procedure -BUT may be normal practice for med consent?? #TwitJC -8:22 PM fidouglas From an outsiders perspective, to me it seems that explaining what a procedure will help with is one of the main things to discuss. #twitjc -8:23 PM silv24 Discussions with patients regarding consent have alot of variables and conversations differ widely. 5 minutes isn't that long really #twitjc -8:23 PM Neuray RT @DrDLittle: Patients often don't understand this sort of idea, impossible to explain properly in 5 mins! #Twitjc -8:23 PM adriamarilla I'll miss #twitjc today so anxious watching my team (paraguay) vs uruguay at the final in copa america! #CA2011 #Paraguay! -8:23 PM fidouglas Is it too difficult to say "This will improve your symptoms, but it's not going to affect whether you have a heart attack"? #twitjc -8:23 PM dean_jenkins Cardiologists are usually charming. RT @iamdoctord: Did the interventionists bias (charm, persuasion) influence the patients? #twitjc -8:23 PM silv24 @fidouglas should be discussing the risks and benefits in detail, have no idea what these patients were actually told #twitjc -8:24 PM northern_doctor @fidouglas Indications, yes. But risks/benefits that aren't clear cut can be difficult to explain & understand. #twitjc -8:24 PM fidouglas @DrDLittle Patients do understand "This will help your angina but won't stop you having a heart attack". It's not difficult. #twitjc -8:24 PM iamdoctord Consent form is exhaustive, but not specific. Form 1's in NI give clinicians opportunity to fill in particular details as applicable #twitjc -8:24 PM PaedsSHO Informed consent in 5 minutes is always a big ask. #twitjc -8:24 PM disabledmedic Maybe also more willing to proceed to appease a patient, because the funding structure is different - no disincentive #twitjc -8:24 PM amcunningham @DrJenGunter @dr_stuart trying to do #twitjc at moment so will get back to you later -8:24 PM silv24 RT @fidouglas: Is it too difficult to say "This will improve your symptoms, but not going to affect whether you have heart attack"? #twitjc -8:24 PM fidouglas @northern_doctor but given the COURAGE study, they should surely have been making it clear to patients that it won't help with MIs. #twitjc -8:25 PM GabrielScally #twitjc Do we think that cardiologists are objective in their advice? Do we think cardiac surgeons are objective in theirs? -8:25 PM iamdoctord The interventionists, (after this study) could say that the likelihood of undergoing a huge operation ie. CABG was reduced. #twitjc -8:25 PM amitns This appears to be such a poorly conceived trial that makes any inference unreliable #TwitJC -8:25 PM
DrDLittle @fidouglas you assume they they know difference between angina and MI. Some don't #Twitjc -8:25 PM silv24 @PaedsSHO sometimes not even 5 minutes is given to consent... #twitjc -8:25 PM PaedsSHO Curses. Have to go to work. Interested to read the transcript. #twitjc -8:25 PM dean_jenkins Is the consent form an opportunity for patient education? Probably not given the timescale and other necessities. #twitjc -8:25 PM northern_doctor Remember also that these patients were being consented for possible, but not definite, procedures. Makes a difference. #twitjc -8:25 PM PHTwitJC #TwitJC -8:26 PM northern_doctor @fidouglas Yes, in principle, but you're assuming total objectivity on part of consent-taker... #twitjc -8:26 PM dean_jenkins Should the person sticking the needle in the patient be the one that does the consent ... always? I think so. #twitjc -8:27 PM disabledmedic consent forms are so much about covering our own arses, that sometimes i think the point of the form gets lost in the box ticking #twitjc -8:27 PM iamdoctord @dean_jenkins completing consent forms should always be an opportunity for education if that is feasible #twitjc -8:27 PM northern_doctor @fidouglas I DO agree with what you're saying about how things SHOULD be done though!! #twitjc -8:27 PM DrDLittle Consent is too often treated as just a necessary (tick-box) hurdle by clinicians. Have been there myself #Twitjc -8:27 PM northern_doctor Yes. RT @dean_jenkins: Should the person sticking the needle in the patient be the one that does the consent ... always? I think so. #twitjc -8:27 PM silv24 RT @DrDLittle: Consent is too often treated as just a necessary (tick-box) hurdle by clinicians. Have been there myself #twitjc -8:27 PM Abe702 @dean_jenkins hard to ensure that happens aint it? #twitjc -8:28 PM amcunningham The patients in the study were consenting to possible PCI.Is there any value in angiogram if don't want stenting? Would you refuse? #twitjc -8:28 PM DrDLittle @disabledmedic totally agree! #Twitjc -8:28 PM fidouglas Still don't know why docs didn't make it clear that PCI would only provide symptomatic relief. Patients have a right to know that. #twitjc -8:28 PM amcunningham @amitns it wasn't a trial! Why do you think poorly conceived? #TwitJC -8:29 PM GabrielScally #twitjc Take a look at what can happen in the UK when consent for PCI is in doubt. http://bit.ly/qdJspX -8:29 PM bajammal RT @twitjournalclub: Second topic: #twitjc -8:29 PM northern_doctor @amcunningham Hmm. Good question. It depends on the specialist. Some would always do it, some wouldn't if it doesn't change things. #twitjc -8:29 PM disabledmedic @amcunningham that's an important point - the group that we're looking at is the group that's elected to go ahead with it #twitjc -8:29 PM
dean_jenkins @Abe702 yes I agree but where the patient is conscious throughout and the treatments well studied by RCTs I think they should try. #twitjc -8:30 PM iamdoctord The mortality statistics suggest that undergoing the procedure was relatively low-harm, unfortunately it was also 'low-benefit' #twitjc -8:30 PM DrDLittle @fidouglas I still think that symptomatic relief is a concept than a significant number of patients don't understand properly #Twitjc -8:30 PM amcunningham @fidouglas we don't know that docs didn't say would reduce mortality. Only that pts thought it would. Sometimes we hear what we want #twitjc -8:30 PM PHTwitJC Consent so tricky: as pt I don't want to take take time by asking qus and assume it's in my best interests -I have a phd! #TwitJC -8:30 PM dean_jenkins Low risk, low benefit, but high remuneration. :-) #twitjc -8:30 PM fidouglas @amcunningham That's a fair point. Can't assume that docs didn't say it, just that patients didn't hear it/take it in. #twitjc -8:31 PM GabrielScally #twitjc Failure to gain proper consent in something as intrusive as PCI must surely put the clinician at risk of an assault charge? -8:31 PM Buzzmf87 @silv24 @paedssho i think regularly less than 5min is given to informed consent! #twitjc -8:31 PM amitns @amcunningham #TwitJC Oops typo. Poorly conceived because not clear what was conveyed & how -8:31 PM iamdoctord Was there a standardised form for patients to read pre-procedure if they were recruited to the study? #twitjc -8:31 PM silv24 would have been interesting if a standard consent proforma had been used - would patients have had similar information then? #twitjc -8:31 PM disabledmedic And people are so scared of risk that they're willing to try a lot of things just on the off chance #twitjc -8:31 PM twitjournalclub Next topic: Why would 43% of cardiologists who identified no benefit in PCI in a hypothetical scenario proceed with it anyway? #twitjc -8:31 PM dean_jenkins Studying PCI consent issues is hard since it is low risk, low benefit (in certain groups) and high remuneration. :-) #twitjc -8:32 PM northern_doctor @fidouglas @amcunningham But, as with capacity, shouldn't it be our job to check understanding? #twitjc -8:32 PM iamdoctord Re Q3. The crude answer would be 'because they can'... #twitjc -8:32 PM amcunningham @amitns aim of study wasn't to determine what really was said.Just perceptions of benefit. Legitimate aim IMHO. Shows this is issue #TwitJC -8:32 PM dean_jenkins 43% of cardiologists proceed with plumbing duties because they just can't help it. #twitjc -8:32 PM DrDLittle So many patients just sign the consent form without really listening. "you're the doctor" <heard several times #Twitjc -8:33 PM silv24 I just wondered whether it would be different in the UK where they wouldn't get paid for doing PCI?? #twitjc -8:33 PM fidouglas @dean_jenkins Do you think the results would have been quite different if the study were conducted in the UK or similar? #twitjc -8:33 PM
iamdoctord The renumeration influence could be a bias for interventionist to undertake work. With advancing technology, incentives are there... #twitjc -8:33 PM silv24 RT @GabrielScally: #twitjc Take a look at what can happen in the UK when consent for PCI is in doubt. http://bit.ly/qdJspX -8:33 PM silv24 RT @GabrielScally: #twitjc Failure to gain proper consent in something as intrusive as PCI must surely put the clinician at risk of an assault charge? -8:33 PM GabrielScally @fidouglas #twitjc Take a look at the GMC case I gave a link to! -8:33 PM northern_doctor In the COURAGE study, there were a higher number of peri-procedural MIs in PCI group (35 vs 9). No p value given. #twitjc -8:34 PM disabledmedic I think money / insurance might have quite a lot to do with it #twitjc -8:34 PM northern_doctor @GabrielScally Wow. Scary. #twitjc -8:34 PM DrDLittle RT @silv24: I just wondered whether it would be different in the UK where they wouldnt get paid for PCI?? <- would be interesting #Twitjc -8:34 PM Abe702 aint it definitely cuz they got paid for doing a PCI, whether it offers any benefit or not!! #twitjc -8:34 PM dean_jenkins @fidouglas I'm not sure but the big limitation of this study is that it was in one centre. Should be reproduced. Any UK volunteers? #twitjc -8:34 PM PHTwitJC ' little incentive to discourage' -are there +ve incentives (eg from med manufacturers); or they feel they ‘might as well’ do it? #TwitJC -8:35 PM alvo23k physicians that saw no benefits in PCI never adequately conveyed this to the patients #twitjc -8:35 PM dean_jenkins The financial structure of the UK is no different. Hospitals get paid for procedures. #twitjc -8:35 PM Abe702 @northern_doctor aint that a lot ... 35? what was the cohort size? #twitjc -8:35 PM amitns @amcunningham Not sure if valid to measure perception of benefit if so many other variables are missing #TwitJC -8:36 PM iamdoctord I think in terms of medical devices, many UK centres would relish a chance at volunteering for study, if devices were subsidized... #twitjc -8:36 PM northern_doctor The issue is complicated slightly by fact that PCI has not been shown to be inferior. Just not superior. #twitjc -8:36 PM DrDLittle Is there any other reason to do it apart from them being paid for it? #Twitjc -8:36 PM GabrielScally #twitjc I don't think that the cash nexus is important. Clinicians are always at risk of having 'belief' in the therapy they practice. -8:36 PM DrDLittle @dean_jenkins clinicians don't seem to focus on that though in the uk #Twitjc -8:36 PM fidouglas @GabrielScally I think such things are classed under civil law, so it would be battery, but yes, I think you're right. #TwitJC -8:36 PM disabledmedic Also, not thinking a procedure is hugely effective, but maybe not knowing for sure, might lead you to go ahead just in case #twitjc -8:37 PM dean_jenkins If it were to be reproduced the survey instrument needs to be validated and qualitative interviews need to be included. #twitjc -8:37 PM
northern_doctor @Abe702 2287 in total. So v small percentage. Not sure how far off significance it was as specific stats for that not mentioned. #twitjc -8:37 PM fidouglas @northern_doctor Inferior/superior to what? #twitjc -8:37 PM iamdoctord If a health tech assessment was done, would PCI be cost effective in reducing Cardiac Surgery ICU bed days??? #twitjc -8:37 PM amcunningham @ePatientDave no probs! #TwitJC -8:37 PM dean_jenkins @DrDLittle well I think it is a big issue at divisional meetings especially in cashstressed Trusts. #twitjc -8:38 PM Buzzmf87 @PaedsSHO @silv24 almost certainly not! I saw someone consented through google translate once! Bt fareky sure didn't understand! #twitjc -8:38 PM northern_doctor @fidouglas Sorry. To best medical management alone. #twitjc -8:38 PM PHTwitJC -‘medicolegal’ concerns + pt expectations mentioned from prev study (p6) i.e. fear being sued if do not do an intervention??#TwitJC -8:38 PM silv24 RT @northern_doctor: The issue is complicated slightly by fact that PCI has not been shown to be inferior. Just not superior. #twitjc -8:38 PM fidouglas @PHTwitJC Surely you're more likely to be sued for intervening and it then going wrong, that doing nothing at all? #twitjc -8:39 PM northern_doctor @PHTwitJC All the more reason for shared decision-making! #twitjc -8:39 PM DrDLittle @dean_jenkins something to look forward to with more seniority? #Twitjc -8:39 PM KateT_health #TwitJC @dean_jenkins I agree qual interviews needed, survey a bit shaky -8:39 PM Abe702 @PHTwitJC u could be sued for not performing an intervention? #twitjc -8:39 PM dean_jenkins @Buzzmf87 @PaedsSHO @silv24 Oh no! What next? Google consent? Would make an interesting App. :-) #twitjc -8:39 PM northern_doctor With no clear-cut answer as to which rx strategy is best, a lot of individual preferences come into play (from docs and patients) #twitjc -8:40 PM dean_jenkins @DrDLittle don't let me put you off. :-) #twitjc -8:40 PM iamdoctord Regarding shared decision making, I did see this article recently http://bit.ly/mEqf2Y on decision making. Could ideas be expanded? #twitjc -8:40 PM twitjournalclub Back to doctor/patient comms: What can doctors do differently to better communicate the benefits of treatment to their patients? #twitjc -8:41 PM KateT_health #TwitJC @fidouglas I think you're right logically re suing maybe I'm thinking along ' crazy litigious US' lines! - 'right' to surgery? -8:41 PM Chestcracker In UK & in European guidelines all elective PCIs must be discussed at MDT with non interventional cardiologist and cardiac surgeon. #TwitJC -8:41 PM silv24 Generally - we are poor at best at communicating risks and benefits of treatment to patients in my humble experience #twitjc -8:42 PM DrDLittle Emphasis that it is the patients decision is important. Often it seems as though we are just asking for permission to do something #Twitjc -8:42 PM northern_doctor Lots of work has been done on the 'best' way to communicate risks/benefits to patines, but there's no single answer IMHO #twitjc -8:42 PM
disabledmedic Really helpful to ask pt to explain things back to you - sadly, there's often not time to properly go over it until fully understood #twitjc -8:42 PM iamdoctord RT @Chestcracker: ...all elective PCIs must be discussed at MDT with non interventional cardiologist and cardiac surgeon. #twitjc -8:42 PM DrDLittle @silv24 totally agree. #Twitjc -8:42 PM GabrielScally #twitjc There's science to patient communication about major decisions. Particularly strong where the decision about radical prostatectomy. -8:43 PM DrDLittle Radiology is a bad example of communication, nobody ever talks about radiation risk for example #Twitjc -8:43 PM fidouglas @DrDLittle But lots of patients just go "Oh, well, I don't know really. I'll just let the doctor do what he thinks is best". #twitjc -8:43 PM northern_doctor One of the skills we need when giving info/taking consent is determining how much has been understood - like with capacity #twitjc -8:43 PM iamdoctord There will always be a small cohort of patients who will 'submit' to the 'best care provided ' by the attending physician #twitjc -8:44 PM silv24 RT @DrDLittle: Radiology is a bad example of communication, nobody ever talks about radiation risk for example #Twitjc -8:44 PM Chestcracker In US there are payment for service issues. Last week a cardiologist had his licence revoked for implanting too many stents #twitjc -8:44 PM silv24 RT @Chestcracker: In US there are payment for service issues. Last week a cardiologist had his licence revoked for implanting too many stents #twitjc -8:44 PM DrDLittle @fidouglas absolutely, we need more time to talk to them in that case. #Twitjc -8:44 PM northern_doctor Valid choice? RT @fidouglas: Lots of patients just go "Oh, well, I dont know really. Ill let the doctor do what he thinks is best". #twitjc -8:45 PM TheMedicator #twitjc Charlie, current FY1 in General Survey, and 'Epic Dismisser of GP referrals' 8:45 PM amcunningham @silv24 just to say there were presentations about PCI at @fimdm Dartmouth summit http://t.co/To7REaH #TwitJC -8:45 PM GabrielScally #twitjc A lot of patients refuse radical prostate surgery when the risks and benefits are properly explained to them. -8:45 PM disabledmedic @fidouglas @DrDLittle and that's really hard to deal with - how do you make someone take responsibility for making the decisions? #twitjc -8:45 PM northern_doctor @fidouglas I think that's sometimes ok if patients have all the info but still can't decide... #twitjc -8:45 PM PHTwitJC #TwitJC re UK did anyone see this http://bit.ly/rh1eS0 re whistleblowing on unnecessary stents? Is this in the past now? -8:46 PM silv24 Consent needs to be done at an appropriate time with patients having time to think about their decision in an elective situation #twitjc -8:46 PM DrDLittle @northern_doctor @fidouglas depends on any conflict of interests but possibly #Twitjc 8:46 PM silv24 RT @amcunningham: @silv24 just to say there were presentations about PCI at @fimdm Dartmouth summit http://t.co/To7REaH #TwitJC -8:46 PM
fidouglas @DrDLittle From my experiences, if you ask if they want a treatment, they can go "Oh, I don't know", get flustered, then guess. #twitjc -8:46 PM northern_doctor Some patients want to decide themselves after hearing info, but some genuinely want to know "what would you do, doc?" #twitjc -8:46 PM GabrielScally #twitjc I met a great guy at WHO who was a retired doctor and acted as a patient advocat. What a great retirement contribution! -8:47 PM iamdoctord RT @silv24: Consent needs to be done at an appropriate time having time to think about their decision in an elective situation #twitjc -8:47 PM ijmarshall #twitjc easy to understand statistics are difficult to come across - often needs Cochrane library and a calculator -8:47 PM TheMedicator #twitjc Charlie, current FY1 in General Surgery and 'Epic Dismisser of GP referrals' Does the 'average' pt understand radiology images?!? -8:47 PM iamdoctord @GabrielScally the patient advocate sounds like a good idea! #twitjc -8:47 PM DrDLittle @northern_doctor I always find it VERY difficult to answer that #Twitjc -8:47 PM northern_doctor Seconded! RT @silv24: Consent needs to be done at an appropriate time with time to think about decision in an elective situation #twitjc -8:48 PM ijmarshall #twitjc a repository of easy to use stats on treatment effects in useful format (nat frequencies) would make a huge difference -8:48 PM JohnDevapriam “@northern_doctor: Beer - check! Pizza - check! #TwitJC is so much more civilised than hospital-based journal clubs…!” Couldn't agree more:) -8:48 PM disabledmedic There is a place for written information, but only alongside proper conversation, and checking understanding as you go #twitjc -8:48 PM DrDLittle RT @silv24: Consent needs to be done at an appropriate time with patients having time to think about decision in elective situation #Twitjc -8:49 PM northern_doctor @DrDLittle Depends on how much good evidence there is to sway you. In the case of PCI, it's clearly not easy to know. #twitjc -8:49 PM fidouglas @ijmarshall I spent five months explaining statistics/risks to patients. 99% of the time you succeed, but it can take a long time. #twitjc -8:49 PM Abe702 @silv24 aint it common practice to consent patients on the day of their operation? #twitjc 8:49 PM silv24 @Abe702 ideally should have been done in clinic beforehand and then checked on day of op in an elective situation #twitjc -8:50 PM DrDLittle @fidouglas @ijmarshall how long in your experience? More than 5 mins? #Twitjc -8:50 PM amcunningham Can I ask if those in #twitjc tonight are familiar with shared decision makingSDM- and patient decision aids? -8:50 PM silv24 @Abe702 when I had my wisdom teeth out consent was done really poorly, and no-one introduced themselves to me. Scary #twitjc -8:51 PM DrDLittle @amcunningham not very #Twitjc -8:51 PM disabledmedic @Abe702 @silv24 mostly. but people should have things explained early on - bc info takes a while to process, and it's a big decision #twitjc -8:51 PM
disabledmedic @amcunningham i'm not, but it sounds really interesting #twitjc -8:51 PM iamdoctord I'm only recently aware of SDM #twitjc -8:52 PM twitjournalclub The final point, which has already been covered a bit: #TwitJC -8:52 PM northern_doctor @amcunningham Within my speciality (stroke), yes. Been involved in some work to represent stat graphically in different ways. #twitjc -8:52 PM twitjournalclub With regards to the consent form, does this paper raise questions about the nature of informed consent? #TwitJC -8:52 PM amitns @amcunningham Experimenting with SDM PDAs , but pt often hear what they want to hear. #TwitJC -8:52 PM mariawolters Hi, I'm an eHealth person, computer scientist, interested in communication, very late to the party. #TwitJC -8:52 PM disabledmedic are there any good SDM resources anyone can point me to? #twitjc -8:53 PM twitjournalclub You can find the consent form for this study here: http://t.co/cdwoWd0 #TwitJC 8:53 PM Abe702 @silv24 blame the dentists :P #twitjc -8:53 PM silv24 The consent form is pretty poor, I wouldn't use it!! #twitjc -8:53 PM iamdoctord @amcunningham are you aware of the Health Foundation calling for an SDM Design Team? #twitjc -8:53 PM DrDLittle In my experience informed consent is done badly and by juniors which is totally wrong! #Twitjc -8:53 PM amitns @disabledmedic Some on NHS choices #TwitJC -8:53 PM ijmarshall @fidouglas in GP, too many treatments to know where to start - but when info is available readily (e.g. statins) pts are interested #twitjc -8:53 PM iamdoctord @disabledmedic this link is a start to work being done in breast surgery http://bit.ly/mEqf2Y #twitjc -8:54 PM disabledmedic I had trouble plodding through the form & I understand all the jargon (most of it!) things need to be thorough, yes, but simple #twitjc -8:54 PM iamdoctord http://www.isdm2011.org/ #twitjc -8:54 PM dean_jenkins RT @Chestcracker: payment for service issues in US. Last week a cardiologist had licence revoked for implanting too many stents #twitjc -8:54 PM PHTwitJC no info on actual procedure on the consent form. Is this normal? #TwitJC -8:56 PM fidouglas @DrDLittle A long time, but it was a long interview. If only explaining 1 statistic (e.g. % decrease risk) then could do in <5 mins. #TwitJC -8:57 PM Chestcracker #twitjc invasive coronary intervention good test for shared decision making. http://www.informedmedicaldecisions.org/ -8:57 PM dean_jenkins As @fidouglas pointed out, it should be relatively easy to spell out the important issues in PCI consent. This hospital didn't. #twitjc -8:57 PM amcunningham @iamdoctord I don't research SDM myself but my colleague @glynelwyn does HF funded http://t.co/l9RqdhO #TwitJC -8:57 PM
northern_doctor It becomes more complicated if you're talking about several different procedures that *might* be needed during procedure #twitjc -8:58 PM PHTwitJC #TwitJC .. but they didn't include the 'written info' a good % of patients said they'd seen 8:58 PM fidouglas @ijmarshall In GP, do you tell patients there's only a ~3% chance their statins will actually help them? #TwitJC -8:58 PM northern_doctor Not saying that's an excuse, but a way needs to be found to communicate this without overloading patients #twitjc -8:59 PM dean_jenkins How do you get the personalities equal in shared decision making? #twitjc -8:59 PM amcunningham Presentation by @shannonbrownlee on decision making around PCI http://t.co/To7REaH #TwitJC -8:59 PM silv24 @northern_doctor see this when consenting for endoscopies...whole list of things patients might need & therefore need consenting for #twitjc -8:59 PM disabledmedic @northern_doctor in that case i think starting and ending w/ basic summary is v useful 'best case xyz', 'worst case xyz' etc #twitjc -8:59 PM northern_doctor I think we're back to the topic we discussed a few weeks ago about treating the population vs the individual!! #twitjc -9:00 PM PHTwitJC Did we discuss the qu-aire? I wondered if the way the qus were structured actually made pts think lower MI risk was 'right' answer #TwitJC -9:00 PM iamdoctord @amcunningham I'd been in touch via email in the past weeks #twitjc -9:00 PM fidouglas I think it's important that we don't patronise patients. Don't need to go into great medical detail, but do tell them the key facts. #twitjc -9:00 PM amcunningham “@glynelwyn: GMC, MPS and MDU are vague about how to present risk of death in different elective (discretionary) surgery. Not good.” #twitjc -9:00 PM northern_doctor @silv24 How much detail is gone into about each of the individual possible necessary further procedures? #twitjc -9:00 PM disabledmedic @dean_jenkins i think you need to know yourself, and your strengths/weaknesses in terms of communication, teamwork etc #twitjc -9:01 PM northern_doctor RT @fidouglas: Important that we dont patronise patients. Dont need to go into great medical detail, but do tell them the key facts. #twitjc -9:01 PM PHTwitJC ..when in fact they weren't that sure before reading qu-aire what benefits were meant to be, just that there must be some? #TwitJC -9:01 PM northern_doctor @fidouglas Well said! #twitjc -9:01 PM dean_jenkins @PHTwitJC agree. Think the questionnaire was weak in this paper. It wasn't validated either. #twitjc -9:01 PM BenCosway @amcunningham RE SDM. Have you seen these? Great tools. http://t.co/ncKI3ZK @glynelwyn #TwitJC -9:01 PM TheMedicator #TwitJC does the consent form not have the procedure listed?!? Or is there a separate 'yellow form' for that?!? Does the pt get a copy too? -9:01 PM fidouglas Docs & pts have different priorities - would docs ever be selective with what they told a patient to encourage them to agree to tx? #twitjc -9:01 PM
dean_jenkins @disabledmedic yes. I was thinking patient versus charming private US cardiologist. :-) #twitjc -9:01 PM iamdoctord RT @fidouglas: I think its important that we dont patronise patients. Dont go into great medical detail, do tell them the key facts. #twitjc -9:02 PM northern_doctor @disabledmedic I think you're right. That's the most important to hear. The rest of the info can then be filled in. #twitjc -9:02 PM silv24 @northern_doctor not that much really. Mostly inpatients having endoscopies on an emergency/urgent basis #twitjc -9:03 PM GabrielScally @TwitJC #twitjc I love the bit in point 6 of the consent form about 'vendors/vendor representatives' being present. Undertakers? Lawyers? -9:03 PM amcunningham And trip database is adding patient decision aids to search very soon! #TwitJC 9:03 PM disabledmedic @dean_jenkins that's always going to be a tricky one ;) #twitjc -9:03 PM DrDLittle @fidouglas yes, I think this happens quite regularly! #Twitjc -9:04 PM northern_doctor Good work! We need more things like this! RT @BenCosway: Great tools. http://t.co/ncKI3ZK #twitjc -9:04 PM silv24 #twitjc RT @glynelwyn Agree consent is a process. Working on this @ CF- qualitative Is with range of professionals - including in cardiology -9:04 PM amcunningham @BenCosway You know I am in this department! #TwitJC b@glynelwyn -9:04 PM KateT_health RT @GabrielScally #twitjc point 6 of the consent form about 'vendors/vendor representatives' being present. Undertakers? Lawyers? -!! -9:04 PM Buzzmf87 @northern_doctor I think that is a very good point and perhaps needs bring up in another paper.. #twitjc -9:05 PM amcunningham @fidouglas why do docs and pts have different priorities? Can we allign? #TwitJC -9:05 PM northern_doctor @fidouglas If they were, but they genuinely believed they were doing it in best interests of pt, does that make it ok...? #twitjc -9:05 PM silv24 My A&E reg would quiz me on risks and benefits of treatment so I would be better able to explain things to patients #twitjc -9:05 PM PHTwitJC I'm checking out now guys. That was fast, furious &thought-provoking. Look fwd to transcript to see the bits I missed! #TwitJC -9:05 PM Buzzmf87 @northern_doctor .... Can we always use evidence based medicine, because it doesnt always apply to the individual! #twitjc -9:06 PM amcunningham @iamdoctord @fidouglas patronising and going into medical detail unrelated? #TwitJC -9:06 PM northern_doctor @silv24 Really good idea! Wish that happened more in clinical teams. #twitjc 9:06 PM amcunningham @northern_doctor no! #TwitJC can't go against pt wishes! @fidouglas -9:07 PM northern_doctor @Buzzmf87 That's a whole other debate! How long have you got? ;-) #twitjc 9:07 PM DrDLittle If risks were explained more would more patients refuse interventions? #Twitjc -9:07 PM
BenCosway @amcunningham You would have thought that might have occurred to me…..! Ha! #TwitJC -9:08 PM iamdoctord 'RT @DrDLittle: If risks were explained more would more patients refuse interventions?' Quite possibly... #twitjc -9:08 PM mandajroberts RT @fidouglas: Docs & pts have different priorities - would docs ever be selective with what they told a patient to encourage them to agree to tx? #twitjc -9:08 PM northern_doctor @amcunningham Not saying I do that BTW!! Just playing devil's advocate! #twitjc -9:08 PM glynelwyn #TwitJC PCI Would be a good area to develop Option Grid - short table comparing options. will support anyone to develop them. -9:09 PM disabledmedic These are the folk who agreed - we don't know about those who didn't get as far as final consent #twitjc -9:09 PM northern_doctor @amcunningham @fidouglas Few would act against patient's wishes, but I'm sure some would try to sway them in one direction... #twitjc -9:09 PM northern_doctor @DrDLittle I bet that's true! #twitjc -9:10 PM iamdoctord RT @glynelwyn: PCI Would be a good area to develop Option Grid - short table comparing options. will support anyone to develop them. #twitjc -9:10 PM disabledmedic @northern_doctor @amcunningham @fidouglas and would they realise that they're doing so? #twitjc -9:10 PM northern_doctor @disabledmedic Possibly not! But does that make them 'bad' docs?? Interesting, isn't it? #twitjc -9:11 PM amitns @northern_doctor Interesting & worrying #TwitJC -9:12 PM disabledmedic @northern_doctor it is interesting - decent reflective practice could be v important there #twitjc -9:13 PM markhawker @DrDLittle We've a study (I think) looking at ways of "presenting" risk in cancer screening. Slides here: http://bit.ly/pAEZmC #Twitjc -9:13 PM amcunningham @glynelwyn have to say this Mayo clinic PDA on PCI is rather lacking on info on mortality benefits! http://t.co/A1YXZDN @vmontori #TwitJC -9:13 PM markhawker @DrDLittle That's not by me by the way. Just some work I know of looking at ways of presenting risk. #Twitjc -9:13 PM amcunningham if you don't give a patient t adequate information to make decision then you can't know their wishes. @northern_doctor @fidouglas #TwitJC -9:14 PM twitjournalclub Thank you everyone for your contributions, do keep chatting away. #twitjc -9:14 PM DrDLittle @markhawker thanks, I'll take a look. #Twitjc -9:15 PM amcunningham @glynelwyn yes! Was interested in @fidouglas perspective on this:) #TwitJC -9:15 PM markhawker @amcunningham Interesting. Would you ask for their generic wishes first and then present them with the options? #TwitJC -9:15 PM Buzzmf87 @northern_doctor yep, too right it is! #twitjc -9:16 PM
northern_doctor @amcunningham @fidouglas I agree (really!) - just speculating how much of patients' wishes come from them vs influenced by docs! #twitjc -9:16 PM DrDLittle How far do you go, should we be discussing in more detail the risks and benefits of all medications? #Twitjc -9:17 PM amitns @northern_doctor And what influences doctors? #TwitJC -9:17 PM amcunningham @markhawker yes- that's a good model:) #TwitJC -9:17 PM twitjournalclub For the time being, we're going to stick with fortnightly sessions, so the next meeting will be on August 7th. #twitjc -9:17 PM alvo23k i would like to see that physicians thoughts = pts understanding of the procedure regardless of whether pts go ahead with it #twitjc -9:17 PM DrDLittle Really interesting topic, good choice for tonight's #twitJC! #Twitjc -9:18 PM twigfish @amcunningham @glynelwyn #twitjc consenter normally delivers the statistics in our trust although 1% death I always find a little curious -9:18 PM silv24 RT @twitjournalclub: For the time being, we're going to stick with fortnightly sessions, so the next meeting will be on August 7th. #twitjc -9:18 PM DrDLittle @twitjournalclub Ooo, many of us will be in new jobs by then! #Twitjc -9:18 PM amcunningham @DrDLittle I'd think so...at least make available #TwitJC -9:19 PM GabrielScally Thanks to the gurus of the JClub yet again. If I was doing it properly I'd write some reflective notes. Cup of tea instead I think! #twitjc -9:19 PM coral_summers Ha, it's funny seeing #twitjc tweets in my personal feed. Keep up the great work! 9:19 PM northern_doctor @twitjournalclub @silv24 @fidouglas Thanks guys for all your hard work with this, as always #twitjc -9:19 PM northern_doctor Cheers everyone - some really interesting chat tonight. Signing off now. #twitjc 9:19 PM
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