Evidence Based Practice versus Patient Centred Care

@WeSpeechies is again proving to be a source of fascinating conversation. During the week October 25 – 31, (David Kinnane, Consumer protections and speech pathology services: Are we doing the right things at the right times?) an excellent paper by Sue Roulstone was posted, “Evidence, expertise, and patient preference in speech-language pathology” in the context of a discussion about whether evidence based practice (EBP) is inconsistent with patient centred care (PCC). There are a number of loosely connected propositions that might lead to this conclusion and I am going to list them here and then discuss them in separate blogposts. Ultimately I will conclude that patient centred care demands that we practice in an evidence based manner.

The arguments in favour of the idea that EBP and PCC are in conflict come from both directions, either there is a worry that the patient’s preferences will be in conflict with the evidence or there is concern that applying the evidence means ignoring the patient, not to mention clinical expertise.

The first objection is that PCC means selecting treatment approaches and practices in accordance with the patient’s preferences and values. I will argue in my first blog that there are several different models of PCC but none of them are the same as ‘consumer driven decision making”, in other words, simply doing what the patient asks. The preferred model, “shared decision making” is fully consistent with EPB.

A second objection is that EPB implies that there is only one treatment option for every case; therefore there is no room for taking the patient’s preferences and values into account. I will argue that the evidence is nearly always about probabilities and general principles. Therefore it is the role of the SLP to work with the patient to determine which evidence is most applicable and then jointly choose among the best alternative courses of action.

A third perspective is that the most patient centred form of care is to apply a treatment to each individual patient and then watch to see if it “worked” because after all, RCTs only apply to groups of other patients, not your current specific patient. Therefore, clinical expertise should be added to the evidence hierarchies as a form of evidence for treatment efficacy. I will argue that you can never determine treatment efficacy by simply observing change in a single patient.

Finally, the arguments made in all of these blogposts will seem a bit abstract. What do you do when the patient persists in a course of action that appears to be in conflict with all evidence? I will recount my experience with this situation and suggest a course of action. As always I invite your comments.

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4 Comments

  1. Shared Decision Making in SLP Practice | Developmental Phonological Disorders
  2. Full Engagement with Evidence and Patients in SLP Practice | Developmental Phonological Disorders
  3. Do our patients prove that speech therapy works? | Developmental Phonological Disorders
  4. CAMs & Speech Therapy | Developmental Phonological Disorders

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