- Email: [email protected]
Personal significance: the third dimension
ESSAY
Essay
Personal significance: the third dimension Kieran G Sweeney, Domhnall MacAuley, Denis Pereira Gray Evidence-based medicine is the new deity in clinical medicine: physicians worship it, managers demand it, and policy makers aspire towards it. Clinical activity in the UK National Health Service is increasingly driven by the principles of evidence-based medicine, and general practice is not immune.1–3 Using this model, clinicians try to turn the patient’s story into a clinical question, and to answer that question by searching for the best relevant evidence, applied in an appropriate manner. We rank that evidence, by convention, according to a hierarchy of study designs and criteria that relate to internal strengths of a study. By definition, such evidence comes from population studies, and the results relate to what happens in groups of people, rather than in an individual. Decisions are based on interpretation of the evidence by objective criteria, distant from the patient and the consultation. Subjective evidence is anathema. In this context, evidence-based medicine is almost always doctor centred; it focuses on the doctor’s objective interpretation of the evidence, and diminishes the importance of human relationships and the role of the other partner in the consultation—the patient. The importance of research evidence is currently weighted with mathematical models, which, within each study, describe its importance according to two levels of significance, statistical and clinical. There is no mystery attached to statistical significance: it is simply the mathematical likelihood that the result did not occur by chance. Clinical significance describes what the results would mean if applied to a population similar to that studied. But, although clinical significance attempts to clarify the potential impact of the research, it applies only to populations or groups of patients. There still remains the difficulty of transposing such population-derived information to the individual person, who may not enter the consulting room with a discrete one-dimensional problem that can readily be turned into an answerable question.4–6 It is in this context that we introduce a third level of significance—personal significance. We believe that unless the characteristics of this level of significance are clearly understood the implementation of new clinical findings will continue to falter at the critical delivery point—the sharing of the medical message between the doctor and an individual patient during the consultation. Such a tertiary level of significance is needed because one cannot enforce a twodimensional model on a multi-dimensional relationship. Evidence from medical research reaches doctors and patients in different ways. Doctors do not always hear of Lancet 1998; 351: 134–36 Institute of General Practice, Postgraduate Medical School, University of Exeter, Barrack Road, Exeter EX2 5DW (Kieran G Sweeney MRCGP, Prof Denis Pereira Gray FRCGP); and 37 Deramore Drive, Belfast (Domhnall MacAuley MRCGP), UK Correspondence to: Dr K G Sweeney
134
new research findings first; patients are no longer passive recipients of information, and they have their own ways of interpreting and responding to new findings. In a traditional model, new research findings are passed to the professional community through the conventional pathways of peer-reviewed journals and clinical meetings. The next step involves the receipt of that evidence by the wider health community—the move from Rogers’ earlier adopters to the majority and ultimately the so-called laggards.7 Of course, the patient may also have heard about the research finding through the media, family, or friends. The crucial step in dissemination occurs during the interaction between doctor and patient, when an individual practitioner interprets and explains the clinical information for and with an individual patient during a one-to-one consultation. This is not a simple transaction. The term “personal significance” helps us to understand the components of this part of the consultation from the perspective both of the clinician, and the person (patient) who may benefit from the information. We already accept that factors associated with the doctor can affect how a message is transmitted and interpreted, but what really matters is what the message means to the patient.8
Statistical significance The mathematical model that underpins statistical thinking in clinical research applies probability—utility calculations of quantitative decision analysis. These models have an almost irresistible appeal in an era where “an answer is not considered to be a real answer unless it is numerical”.9 The crucial advantage that these mathematical models constantly seek is the reproducibility of the data produced by investigation. Scientists who are concerned about including qualitative factors into evidence-based doctor-patient transactions should recognise, however, that these statistical models also have limitations. The accepted value for statistical significance, p<0·05, is based on the understanding that in any Gaussian distribution of a continuous variable, 95% of the data are included in a zone that is covered by 1.96 standard deviations of the mean. The 5% of data that do not fall within this span should be regarded as inconsistent with the main distribution. Statistical significance is the term used to indicate the probability of clinical data falling within this span.10 Sceptics, however, have developed a series of concerns about the derivation of this model of significance. Firstly, the primary reasoning behind this calculation of p does not fit easily with the distribution of many kinds of data found in clinical medicine. Secondly, this type of frequentist theory, which has dominated medical research for much of this century, creates a dichotomy in which results are regarded as either significant or not. Arguing in favour of a change of model towards Bayesian statistics, Lilford and Braunholtz offer the view that
THE LANCET • Vol 351 • January 10, 1998
ESSAY
dichotomous results (either it is or it isn’t) do not take into account relevant evidence obtained outside the index experiment, which may be important in formulating clinical policies.11 Out of such dichotomous reasoning emerges the paradox that very small differences will eventually “become” significant if repeated often enough in a very large series. Thirdly, human factors can also affect statistical interpretation. A single summary outcome statistic cannot capture satisfactorily the heterogeneity of the combined experience of the individuals in a clinical trial. Such calculations fail to address the issue of auxometry (rate of progression of illness). Patients who have the same disease at the point of entry in a trial may have different patterns of the illness, with differing rates of progression and different clinical features, which can affect both treatment and prognosis.10 Thus, although statistical significance does have limitations, its importance lies in the early stages of the interpretation of research findings. Whereas those with an understanding of critical appraisal and epidemiology may be able to detect the statistical limitations in published research, many clinicians, especially those in primary care, will depend on others, including the peer-review and editorial process, to establish the statistical legitimacy of a research study.
Clinical significance Although results may be statistically significant, the clinician is helped to interpret such evidence with the calculations that collectively constitute clinical significance. In general, there are four key calculations— absolute risk reduction, risk ratio, relative risk reduction (the complement of risk ratio expressed as a percentage), and the concept of numbers needed to treat (the inverse of the absolute risk reduction).12 These concepts, particularly the number needed to treat, have been of special value to clinicians in helping them interpret the results of trials. But what remains unresolved is the precise boundary at which a distinction between two means or two rates can be regarded as quantitatively significant—to the same extent that the stochastic component of statistical significance lies at 0·05. In their review, Burnand and colleagues13 noted the boundaries that were being used by general medical journals to trigger such quantitative decisions in research that contrasts two means, two rates, or two correlation coefficients. They found that this boundary was reached when the ratio of the smaller to the larger mean was greater than 1·2, where the odds ratio was greater than 2·2, and where the r value for correlation coefficient was greater than 0·32. But these conclusions are based only on the authors’ reporting of the interpretative comments of the component studies in the review: they do not represent a consensus view. Clinical significance is thus an important additional factor that can help our interpretation of research findings for regional, district, or practice populations. But the whole aim of producing such evidence and calculating statistics lies in clarifying the clinical dilemma for the patient: thus, the most important application of such findings lies in the context of the individual consultation, during which such information is tailored to the individual personal context of the patient.
THE LANCET • Vol 351 • January 10, 1998
Personal significance Personal significance adds a further dimension and is the key to the transfer of an idea to, and in the evaluation and interpretation of the idea by, the doctor and the patient together. Personal significance is thus a dialectic, consisting of a contribution from the practitioner, who outlines the concept as the practitioner understands it, and the person who receives and evaluates the new idea. The contribution of the doctor is threefold: evaluating the research evidence, exploring the patient’s philosophy of health, and delivering an opinion based on a synthesis of the two. Doctors evaluate evidence in different ways. Usually, they will have an opportunity to evaluate information independently, before engaging in a consultation. But doctors are people too: they are not immune from fears, prejudices, and attitudes to health by virtue of a medical education. The evaluation process is not simply an intellectual procedure, but includes both cognitive and intuitive components. This process has best been described as an “inner consultation” by Neighbour,14 in which a dialogue takes place between what he terms the organiser (logical part of the process) and the responder (the more intuitive component). We argue that doctors conduct an inner consultation with biomedical evidence before deciding how to apply it. Although the doctor’s organiser responds in an analytical, logical way, the evaluation of new evidence is also influenced by his or her background, experience, and other individual factors. Thus, the doctor’s responder will act in a more intuitive manner, using pattern recognition and the association of ideas in a Gestalt way. The responder is sensitive to internal messages determined by the doctor’s feelings and emotion, and this affects the interpretation of information in a way that recognises context, experience, apprehensions, failures, and successes. Furthermore, the consultation occurs at one point in what may be a long-standing doctor-patient relationship. It is dynamic and ever changing, so that the interaction between organiser and responder, and between the product of that dialogue and the influence of the patient, evolves over time. For the experienced doctor the logical (organising) processes become less important, and are replaced by historical pattern analysis or script recognition from exposure to previous similar problems— a responder function. This is what distinguishes the thinking of novices from that of experts.15 The second part of the doctor’s role in personal significance involves exploring the patient’s health philosophy. The clinician and patient may have different priorities so that the traditional health-care philosophy of the medical profession may not be shared by an individual citizen. For the most part, medicine assumes that disease-free longevity is desirable, even at the expense of matters that patients think are of more immediate and substantial concern.16 Consider the elderly husband suffering from arthritis, macular degeneration, and advanced maturity-onset diabetes, whose wife suddenly dies of a stroke. That person may find he no longer wants to live, and begins to take decisions about the care of the diabetes that may not be fully in line with expert professional advice. If patients’ priorities are different from those of the clinician, the quality of medical evidence matters little—the clinician’s advice based upon it will be ignored. Finally, the style and method of communication may also affect the message, and contribute to the patient’s 135
ESSAY
personal significance. A doctor’s own experience, either privately or professionally, will influence the words and nuances used in discussion. For example, the doctor who wrongly diagnosed a benign breast cyst that turned out to be a breast carcinoma, will alter his future behaviour and management of women who present with fibroadenosis in a way that is coloured by this experience. It is almost impossible for doctors to be clinically dispassionate or completely neutral about a topic: their view is a product of both cognitive and experiential evidence. But it is the patient’s contribution that is more important in creating personal significance. In a consultation the patient adds to previous intellectual and emotional understanding of an illness experience.17,18 Patients are not passive recipients waiting for doctors to make decisions about their health: the evidence suggests that the more actively patients participate in consultations, the better controlled are their chronic diseases.19 Attitudes to health are not exclusively logical. People’s attitudes to health, and the decisions taken, are determined by how they perceive a particular threat to health, their belief in the advantages gained from a change in behaviour to accommodate that threat, and how difficult they believe that behaviour change to be. The beliefs that form attitudes to health are influenced by personal and family factors, and by social and demographic factors.20 Actions based upon these beliefs are not always rational; they can be emotional or habitual.21 Patients are influenced in the actions they take by what they think others might expect them to do, and by how much importance they attach to that.22 Of course, this analysis applies equally to the doctor as a person, not as a professional. As Kant said, “we see things not as they are, but as we are”.23 The implications of these observations—better recognised outside the medical profession than within it—have recently been re-stated by McCormack:24 “It is as important to know the patient who has the disease, as it is the disease which the patient has”. Such observations underscore the need to understand the doctor’s personal perspective, the need to recognise the uniqueness of a patient’s personhood,25 and to tailor the delivery of clinical evidence in this light. They also recognise that there may be a philosophical gap between the doctor’s own modernist model, and the post-modernist views of some patients.26
Evidence-based medicine has until now focused on the quality of the message, and clarified the health professional’s responsibility to use the best available knowledge to underpin clinical care. What we need to concentrate on now is clarifying these issues at the level of the recipient of clinical messages—-the patient. We still know little about how to unlock the processes involved in the delivery of clinical messages to an autonomous individual, and their subsequent evaluation. Personal significance is the key.
References 1
2
3
4 5 6 7 8 9
10 11 12 13
14 15 16 17 18 19
Challenge for the future Recognising personal significance presents three challenges for health-care professionals. First, it requires the recognition of the influence of the doctor’s personal characteristics in the transmission of a clinical message. Second, it challenges doctors to collaborate with the professions outside medicine who have already shown a serious interest in this area, analysing in particular the gap between intention to act and activity.21 These include disciplines such as behavioural psychology, social sciences, and education. Third, acknowledging that patients’ health beliefs and attitudes can modify the clinical message should encourage doctors to explore these unique health behaviours and understand how they influence practice. These challenges are not intrinsically radical: they reflect the current evolving philosophy of primary care, described by McWhinney27 and Pereira Gray,28 among others.
136
20 21
22 23 24 25 26 27
28
Secretary of State for Health (1996). Promoting clinical effectiveness. A framework for action in and through the NHS. London: NHS Executive, 1996 Evidence Based Medicine Working Group. Evidence based medicine: A new approach to teaching the practice of medicine. JAMA 1992; 268: 2420–25. Gill P, Dowell AC, Neal RD, Smith N, Heywood P, Wilson AE. Evidence based general practice: a retrospective study on interventions in one training practice. BMJ 1996; 312: 819–21. Editorial. Evidence based medicine, in its place. Lancet 1995; 346: 785. Greenhalgh T. Is my practice evidence based? BMJ 1996; 313: 9575–78 Charlton R. Balancing science and art in primary care research: past and present. Br J Gen Pract 1995 45: 639–40. Rogers EM. Diffusion of innovations. New York: The Free Press, 1983. Balint M. The doctor, his patient and the illness. New York: International Universities Press, 1957. Rudebeck CE. General practice and a dialogue of clinical practice: on symptoms, symptom presentations, and bodily empathy. Scand J Primary Health Care 1992; Supplement 1. Feinstein AR. Insidious comparisons and unmet clinical challenges. Am J Med 1992; 92: 117–20. Lilford RJ, Braunholtz D. The statistical basis of public policy: a paradigm shift is overdue. BMJ 1996; 313: 603–07. Sackett DL, Haines RB, Tugwell P. Clinical epidemiology. Boston, MA: Little Brown, 1985. Burnand B, Kernan WN, Feinstein AR. Indexes and boundaries for quantitative significance in statistical significance. J Clin Epidemiol 1990; 43: 1273–84. Neighbour R. The inner consultation. Lancaster: MTP Press, 1987. Van Der Veuten CPM. How can we test clinical reasoning? Lancet 1995; 345: 1032–34. Landaue L, Gustaffson J. Death is not the enemy. JAMA 1984; 252: 2458. Cromarty I. What do patients think about during their consultations? A qualitative study. Br J Gen Prac 1996; 46: 525–28. Heath I. The mystery of general practice. London: Nuffield Provincial Hospitals Trust, 1995 Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physicianspatient interactions on the outcomes of chronic disease. Med Care 1989; 27.3 (suppl): S125. Becker MH. The health belief model and sick role behaviour. Health Educ Monographs 1974; 2: 409-19. Johnston M. Health related behaviour change. In: Preventing coronary heart disease in primary care: the way forward. London: Kings Fund, 1974. Fishbein M, Azjen I. Belief, attitude, intention and behaviour. New York: Wiley, 1975. Russell B. The history of western philosophy. London: Unwin Paperbacks, 1961. McCormack J. The death of the personal doctor. Lancet 1996; 348: 667–68. Cassell E. The nature of suffering. Oxford: Oxford University Press, 1991. Charlton B. Medicine and postmodernity. J R Soc Med 1993; 86: 497–99. McWhinney IR . Primary care research in the next twenty years. In: Norton P, Stewart M, Tudiver F, Bass M, Dunn E, eds. Primary care research traditional and innovative approaches. Newbury Park: Sage, 1991: 1–12 Periera Gray DJ. Primary care and public health. Health Hyg 1995; 16: 49–62.
THE LANCET • Vol 351 • January 10, 1998
Essay
Personal significance: the third dimension Kieran G Sweeney, Domhnall MacAuley, Denis Pereira Gray Evidence-based medicine is the new deity in clinical medicine: physicians worship it, managers demand it, and policy makers aspire towards it. Clinical activity in the UK National Health Service is increasingly driven by the principles of evidence-based medicine, and general practice is not immune.1–3 Using this model, clinicians try to turn the patient’s story into a clinical question, and to answer that question by searching for the best relevant evidence, applied in an appropriate manner. We rank that evidence, by convention, according to a hierarchy of study designs and criteria that relate to internal strengths of a study. By definition, such evidence comes from population studies, and the results relate to what happens in groups of people, rather than in an individual. Decisions are based on interpretation of the evidence by objective criteria, distant from the patient and the consultation. Subjective evidence is anathema. In this context, evidence-based medicine is almost always doctor centred; it focuses on the doctor’s objective interpretation of the evidence, and diminishes the importance of human relationships and the role of the other partner in the consultation—the patient. The importance of research evidence is currently weighted with mathematical models, which, within each study, describe its importance according to two levels of significance, statistical and clinical. There is no mystery attached to statistical significance: it is simply the mathematical likelihood that the result did not occur by chance. Clinical significance describes what the results would mean if applied to a population similar to that studied. But, although clinical significance attempts to clarify the potential impact of the research, it applies only to populations or groups of patients. There still remains the difficulty of transposing such population-derived information to the individual person, who may not enter the consulting room with a discrete one-dimensional problem that can readily be turned into an answerable question.4–6 It is in this context that we introduce a third level of significance—personal significance. We believe that unless the characteristics of this level of significance are clearly understood the implementation of new clinical findings will continue to falter at the critical delivery point—the sharing of the medical message between the doctor and an individual patient during the consultation. Such a tertiary level of significance is needed because one cannot enforce a twodimensional model on a multi-dimensional relationship. Evidence from medical research reaches doctors and patients in different ways. Doctors do not always hear of Lancet 1998; 351: 134–36 Institute of General Practice, Postgraduate Medical School, University of Exeter, Barrack Road, Exeter EX2 5DW (Kieran G Sweeney MRCGP, Prof Denis Pereira Gray FRCGP); and 37 Deramore Drive, Belfast (Domhnall MacAuley MRCGP), UK Correspondence to: Dr K G Sweeney
134
new research findings first; patients are no longer passive recipients of information, and they have their own ways of interpreting and responding to new findings. In a traditional model, new research findings are passed to the professional community through the conventional pathways of peer-reviewed journals and clinical meetings. The next step involves the receipt of that evidence by the wider health community—the move from Rogers’ earlier adopters to the majority and ultimately the so-called laggards.7 Of course, the patient may also have heard about the research finding through the media, family, or friends. The crucial step in dissemination occurs during the interaction between doctor and patient, when an individual practitioner interprets and explains the clinical information for and with an individual patient during a one-to-one consultation. This is not a simple transaction. The term “personal significance” helps us to understand the components of this part of the consultation from the perspective both of the clinician, and the person (patient) who may benefit from the information. We already accept that factors associated with the doctor can affect how a message is transmitted and interpreted, but what really matters is what the message means to the patient.8
Statistical significance The mathematical model that underpins statistical thinking in clinical research applies probability—utility calculations of quantitative decision analysis. These models have an almost irresistible appeal in an era where “an answer is not considered to be a real answer unless it is numerical”.9 The crucial advantage that these mathematical models constantly seek is the reproducibility of the data produced by investigation. Scientists who are concerned about including qualitative factors into evidence-based doctor-patient transactions should recognise, however, that these statistical models also have limitations. The accepted value for statistical significance, p<0·05, is based on the understanding that in any Gaussian distribution of a continuous variable, 95% of the data are included in a zone that is covered by 1.96 standard deviations of the mean. The 5% of data that do not fall within this span should be regarded as inconsistent with the main distribution. Statistical significance is the term used to indicate the probability of clinical data falling within this span.10 Sceptics, however, have developed a series of concerns about the derivation of this model of significance. Firstly, the primary reasoning behind this calculation of p does not fit easily with the distribution of many kinds of data found in clinical medicine. Secondly, this type of frequentist theory, which has dominated medical research for much of this century, creates a dichotomy in which results are regarded as either significant or not. Arguing in favour of a change of model towards Bayesian statistics, Lilford and Braunholtz offer the view that
THE LANCET • Vol 351 • January 10, 1998
ESSAY
dichotomous results (either it is or it isn’t) do not take into account relevant evidence obtained outside the index experiment, which may be important in formulating clinical policies.11 Out of such dichotomous reasoning emerges the paradox that very small differences will eventually “become” significant if repeated often enough in a very large series. Thirdly, human factors can also affect statistical interpretation. A single summary outcome statistic cannot capture satisfactorily the heterogeneity of the combined experience of the individuals in a clinical trial. Such calculations fail to address the issue of auxometry (rate of progression of illness). Patients who have the same disease at the point of entry in a trial may have different patterns of the illness, with differing rates of progression and different clinical features, which can affect both treatment and prognosis.10 Thus, although statistical significance does have limitations, its importance lies in the early stages of the interpretation of research findings. Whereas those with an understanding of critical appraisal and epidemiology may be able to detect the statistical limitations in published research, many clinicians, especially those in primary care, will depend on others, including the peer-review and editorial process, to establish the statistical legitimacy of a research study.
Clinical significance Although results may be statistically significant, the clinician is helped to interpret such evidence with the calculations that collectively constitute clinical significance. In general, there are four key calculations— absolute risk reduction, risk ratio, relative risk reduction (the complement of risk ratio expressed as a percentage), and the concept of numbers needed to treat (the inverse of the absolute risk reduction).12 These concepts, particularly the number needed to treat, have been of special value to clinicians in helping them interpret the results of trials. But what remains unresolved is the precise boundary at which a distinction between two means or two rates can be regarded as quantitatively significant—to the same extent that the stochastic component of statistical significance lies at 0·05. In their review, Burnand and colleagues13 noted the boundaries that were being used by general medical journals to trigger such quantitative decisions in research that contrasts two means, two rates, or two correlation coefficients. They found that this boundary was reached when the ratio of the smaller to the larger mean was greater than 1·2, where the odds ratio was greater than 2·2, and where the r value for correlation coefficient was greater than 0·32. But these conclusions are based only on the authors’ reporting of the interpretative comments of the component studies in the review: they do not represent a consensus view. Clinical significance is thus an important additional factor that can help our interpretation of research findings for regional, district, or practice populations. But the whole aim of producing such evidence and calculating statistics lies in clarifying the clinical dilemma for the patient: thus, the most important application of such findings lies in the context of the individual consultation, during which such information is tailored to the individual personal context of the patient.
THE LANCET • Vol 351 • January 10, 1998
Personal significance Personal significance adds a further dimension and is the key to the transfer of an idea to, and in the evaluation and interpretation of the idea by, the doctor and the patient together. Personal significance is thus a dialectic, consisting of a contribution from the practitioner, who outlines the concept as the practitioner understands it, and the person who receives and evaluates the new idea. The contribution of the doctor is threefold: evaluating the research evidence, exploring the patient’s philosophy of health, and delivering an opinion based on a synthesis of the two. Doctors evaluate evidence in different ways. Usually, they will have an opportunity to evaluate information independently, before engaging in a consultation. But doctors are people too: they are not immune from fears, prejudices, and attitudes to health by virtue of a medical education. The evaluation process is not simply an intellectual procedure, but includes both cognitive and intuitive components. This process has best been described as an “inner consultation” by Neighbour,14 in which a dialogue takes place between what he terms the organiser (logical part of the process) and the responder (the more intuitive component). We argue that doctors conduct an inner consultation with biomedical evidence before deciding how to apply it. Although the doctor’s organiser responds in an analytical, logical way, the evaluation of new evidence is also influenced by his or her background, experience, and other individual factors. Thus, the doctor’s responder will act in a more intuitive manner, using pattern recognition and the association of ideas in a Gestalt way. The responder is sensitive to internal messages determined by the doctor’s feelings and emotion, and this affects the interpretation of information in a way that recognises context, experience, apprehensions, failures, and successes. Furthermore, the consultation occurs at one point in what may be a long-standing doctor-patient relationship. It is dynamic and ever changing, so that the interaction between organiser and responder, and between the product of that dialogue and the influence of the patient, evolves over time. For the experienced doctor the logical (organising) processes become less important, and are replaced by historical pattern analysis or script recognition from exposure to previous similar problems— a responder function. This is what distinguishes the thinking of novices from that of experts.15 The second part of the doctor’s role in personal significance involves exploring the patient’s health philosophy. The clinician and patient may have different priorities so that the traditional health-care philosophy of the medical profession may not be shared by an individual citizen. For the most part, medicine assumes that disease-free longevity is desirable, even at the expense of matters that patients think are of more immediate and substantial concern.16 Consider the elderly husband suffering from arthritis, macular degeneration, and advanced maturity-onset diabetes, whose wife suddenly dies of a stroke. That person may find he no longer wants to live, and begins to take decisions about the care of the diabetes that may not be fully in line with expert professional advice. If patients’ priorities are different from those of the clinician, the quality of medical evidence matters little—the clinician’s advice based upon it will be ignored. Finally, the style and method of communication may also affect the message, and contribute to the patient’s 135
ESSAY
personal significance. A doctor’s own experience, either privately or professionally, will influence the words and nuances used in discussion. For example, the doctor who wrongly diagnosed a benign breast cyst that turned out to be a breast carcinoma, will alter his future behaviour and management of women who present with fibroadenosis in a way that is coloured by this experience. It is almost impossible for doctors to be clinically dispassionate or completely neutral about a topic: their view is a product of both cognitive and experiential evidence. But it is the patient’s contribution that is more important in creating personal significance. In a consultation the patient adds to previous intellectual and emotional understanding of an illness experience.17,18 Patients are not passive recipients waiting for doctors to make decisions about their health: the evidence suggests that the more actively patients participate in consultations, the better controlled are their chronic diseases.19 Attitudes to health are not exclusively logical. People’s attitudes to health, and the decisions taken, are determined by how they perceive a particular threat to health, their belief in the advantages gained from a change in behaviour to accommodate that threat, and how difficult they believe that behaviour change to be. The beliefs that form attitudes to health are influenced by personal and family factors, and by social and demographic factors.20 Actions based upon these beliefs are not always rational; they can be emotional or habitual.21 Patients are influenced in the actions they take by what they think others might expect them to do, and by how much importance they attach to that.22 Of course, this analysis applies equally to the doctor as a person, not as a professional. As Kant said, “we see things not as they are, but as we are”.23 The implications of these observations—better recognised outside the medical profession than within it—have recently been re-stated by McCormack:24 “It is as important to know the patient who has the disease, as it is the disease which the patient has”. Such observations underscore the need to understand the doctor’s personal perspective, the need to recognise the uniqueness of a patient’s personhood,25 and to tailor the delivery of clinical evidence in this light. They also recognise that there may be a philosophical gap between the doctor’s own modernist model, and the post-modernist views of some patients.26
Evidence-based medicine has until now focused on the quality of the message, and clarified the health professional’s responsibility to use the best available knowledge to underpin clinical care. What we need to concentrate on now is clarifying these issues at the level of the recipient of clinical messages—-the patient. We still know little about how to unlock the processes involved in the delivery of clinical messages to an autonomous individual, and their subsequent evaluation. Personal significance is the key.
References 1
2
3
4 5 6 7 8 9
10 11 12 13
14 15 16 17 18 19
Challenge for the future Recognising personal significance presents three challenges for health-care professionals. First, it requires the recognition of the influence of the doctor’s personal characteristics in the transmission of a clinical message. Second, it challenges doctors to collaborate with the professions outside medicine who have already shown a serious interest in this area, analysing in particular the gap between intention to act and activity.21 These include disciplines such as behavioural psychology, social sciences, and education. Third, acknowledging that patients’ health beliefs and attitudes can modify the clinical message should encourage doctors to explore these unique health behaviours and understand how they influence practice. These challenges are not intrinsically radical: they reflect the current evolving philosophy of primary care, described by McWhinney27 and Pereira Gray,28 among others.
136
20 21
22 23 24 25 26 27
28
Secretary of State for Health (1996). Promoting clinical effectiveness. A framework for action in and through the NHS. London: NHS Executive, 1996 Evidence Based Medicine Working Group. Evidence based medicine: A new approach to teaching the practice of medicine. JAMA 1992; 268: 2420–25. Gill P, Dowell AC, Neal RD, Smith N, Heywood P, Wilson AE. Evidence based general practice: a retrospective study on interventions in one training practice. BMJ 1996; 312: 819–21. Editorial. Evidence based medicine, in its place. Lancet 1995; 346: 785. Greenhalgh T. Is my practice evidence based? BMJ 1996; 313: 9575–78 Charlton R. Balancing science and art in primary care research: past and present. Br J Gen Pract 1995 45: 639–40. Rogers EM. Diffusion of innovations. New York: The Free Press, 1983. Balint M. The doctor, his patient and the illness. New York: International Universities Press, 1957. Rudebeck CE. General practice and a dialogue of clinical practice: on symptoms, symptom presentations, and bodily empathy. Scand J Primary Health Care 1992; Supplement 1. Feinstein AR. Insidious comparisons and unmet clinical challenges. Am J Med 1992; 92: 117–20. Lilford RJ, Braunholtz D. The statistical basis of public policy: a paradigm shift is overdue. BMJ 1996; 313: 603–07. Sackett DL, Haines RB, Tugwell P. Clinical epidemiology. Boston, MA: Little Brown, 1985. Burnand B, Kernan WN, Feinstein AR. Indexes and boundaries for quantitative significance in statistical significance. J Clin Epidemiol 1990; 43: 1273–84. Neighbour R. The inner consultation. Lancaster: MTP Press, 1987. Van Der Veuten CPM. How can we test clinical reasoning? Lancet 1995; 345: 1032–34. Landaue L, Gustaffson J. Death is not the enemy. JAMA 1984; 252: 2458. Cromarty I. What do patients think about during their consultations? A qualitative study. Br J Gen Prac 1996; 46: 525–28. Heath I. The mystery of general practice. London: Nuffield Provincial Hospitals Trust, 1995 Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physicianspatient interactions on the outcomes of chronic disease. Med Care 1989; 27.3 (suppl): S125. Becker MH. The health belief model and sick role behaviour. Health Educ Monographs 1974; 2: 409-19. Johnston M. Health related behaviour change. In: Preventing coronary heart disease in primary care: the way forward. London: Kings Fund, 1974. Fishbein M, Azjen I. Belief, attitude, intention and behaviour. New York: Wiley, 1975. Russell B. The history of western philosophy. London: Unwin Paperbacks, 1961. McCormack J. The death of the personal doctor. Lancet 1996; 348: 667–68. Cassell E. The nature of suffering. Oxford: Oxford University Press, 1991. Charlton B. Medicine and postmodernity. J R Soc Med 1993; 86: 497–99. McWhinney IR . Primary care research in the next twenty years. In: Norton P, Stewart M, Tudiver F, Bass M, Dunn E, eds. Primary care research traditional and innovative approaches. Newbury Park: Sage, 1991: 1–12 Periera Gray DJ. Primary care and public health. Health Hyg 1995; 16: 49–62.
THE LANCET • Vol 351 • January 10, 1998