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Evidence Based Medicine. Myths, truths and things in between – a blog for everyone

Steve Turner

In producing a teaching session on evidence based medicine, it occurred to me that there are some important points everyone needs to know, and that they are summarised well in these videos from James McCormack.

So if you like learning through the medium of song and dance, these are for you 😃.

There are some links to important guidelines and academic references too. Some of the comments on learning points reflect my personal views.

Assessing the evidence

‘Viva La Evidence’ from James McCormack

Key learning points:

Look for absolute numbers. To assess clinical studies you need to have sight of the ‘absolute numbers’ and the figure for Absolute Risk Reduction [ARR]. Sales and marketing people may just tell us about Relative Risk Reduction [RRR]. This figure stays constant with different populations, and always looks better. To be honest I find this concept easy to understand but hard to explain. Here’s a link to an article which goes in to more detail.

POOs and DOOs. It’s helpful to look closely at the relevance of the research for patients. Is it focused on outcomes that are patient-oriented [POOs] or disease-oriented outcomes [DOOs]? Click here for a related article.

‘The End of Guidelines’ – how useful are they in real life

‘The end of Guidelines’ – from James McCormack

Key learning point:

Guidelines not tramlines

Most current guidelines are written for specific diseases and conditions when, in reality many people often have more than one long term condition. In fact, most people with chronic conditions, and most of people over 65, have multiple health conditions. This together with other influences such as past experiences, health beliefs, ethnicity, poverty, lifestyle and cultural factors, will influence the choice of medicines.

To help with this there are some important NICE Guidelines, which should be cross referenced in practice guidance (local and national).

  1. NICE guideline [NG56] Multi Morbidity and Clinical Assessment
  2. NICE Guideline [CG 76] on Medicines Adherence
  3. NICE Guideline on Shared Decision Making (2021)

All prescribers should be familiar with and use these guidelines in helping patients choose medicines & treatments. This includes the patient’s choice not to take a medicine, which is specifically noted in the NICE Guideline on Medicines Adherence.

Guidelines are just that – ‘guidelines’ – and not to be followed blindly without question or reference to the individual patient.

GUIDELINES NOT TRAMLINES – National Institute for Health & Care Excellence in England [NICE]

Alternatives to medicines – Choosing wisely

‘Choosing wisely’ from James McCormack

Key learning point:

‘Top down medicine is dead’

We are best experts in our own care.

The clinician’s role has changed from being the ‘expert’ to that of a teacher, advisor, mentor and sometimes an advocate. At the end of the day, in everyday situations, what we do is our decision. The much used phrase ‘shared decision making’ is inappropriate in my view, it stems from the old fashioned ‘doctor knows best’ attitude. I prefer to use the phrase patient led decision making.

Click here for more on our patient led clinical education work.

  • Steve Turner

Steve Turner is a nurse prescriber and clinical educator.

Comments welcome: steve@carerightnow.co.uk

Click here for more links to Steve’s work

Page last updated: 09.11.2021

Mum’s Story – Mavis Turner 1929 – 2020

Steve Turner
Mum aged 8 months and the Challenge Shield – 1930

Mavis Bowers was born prematurely on 26th September 1929, at home in Bull Hill Stafford. She had a twin brother David who only lived for a short while. Mum was ‘smaller than a bag of sugar’ when she was born and for the first weeks of her life had to be washed in olive oil, dressed in doll’s clothes and a small drawer was used as a cot. Her birth wasn’t registered for two months.


When the picture of mum and the challenge shield was taken mum was eight months’ old, & still not able to sit up for herself. The wooden “Challenge Shield” was an engraved silver plaque for “Stafford Infant Welfare Centre’s Annual Competition for infants during their first year”. This began in 1920 and ended in 1948 (the year the NHS was set up). Mothers who won were presented with one small shield which they could keep, and the large ‘Challenge Shield’ which they kept for 12 months. They also pushed the baby in a pram along Stafford’s main street at Stafford Pageant. The silver plaque was made by G & S Ltd.
Mavis’s mother Frances Bowers brought up her three daughters on her own. They lived in Prospect Road, Coton Fields, Stafford.

Mavis in her dad’s arms, with sisters Olive and Joyce


Another picture shows Mum and her older sisters, Olive and Joyce with mum in her dad William Bowers’ arms . Shortly after this my grandad William went into St George’s Hospital, where he remained until he died, about 30 years later. Mum can remember visiting him in the hospital as a young child. She described how there were many doors to unlock and how the attendants (this was before mental health nurses) were very kind to her and her mother.
We now know granddad had some sort of post traumatic illness, although at the time people didn’t talk about it, and it was said he had been ‘gassed in the first world war’. We have now found out that Fabry disease runs in the family (originating on mum’s side). This rare enzyme disorder, which causes limb pain and organ degeneration, has been misdiagnosed as a mental illness in the past. We wonder if that’s what granddad was suffering from.

Frances Jane Bowers – Mavis Turner’s mother

Mavis and her two sisters brought up in poverty by their mum Frances. Mum remembers her childhood as happy and secure. One of mum’s memories was being sent by her mum to fetch dripping from a local hospital. (Dripping is the fat and juices that come off roast meats.) Mum and her sisters had to take a walk across some fields, where they used to be frightened of the horses, and knock at the kitchen door of the hospital. They then gave a penny for a jug to be filled with dripping. Mum also remembered how her mother used to wash and dry the girl’s school clothes every night, as they only had one set of school uniforms.

Mum aged 18 in a dress she made herself.

Mum’s upbringing made her really appreciative of the small things in life and never to take anything for granted.

Mavis and Jim Turner

After leaving school at 14 Mavis started training as a seamstress and later worked at Lotus shoe factory. Mavis Bowers married Jim Turner a chartered electrical engineer, originally from Plymouth, who worked at English Electric in Stafford, and went on to have two sons, Steve and Nick. Mavis enjoyed sewing and, after the children left, worked from home as a seamstress. Mavis and Jim enjoyed travel and visited Europe often when they were older. At the age of 70 Mavis also went to Australia on her own and had the holiday of a lifetime travelling from Melbourne to Townsville in north Queensland, visiting friends of her son Steve who have lived there for 5 years. After 59 years of marriage Jim Turner died in 2016.

Mungo Lakes, New South Wales,Australia – acrylic on canvas -Mavis Turner

Mum took up paintings at age 80 and completed several pictures, some abstract and some from memory. The picture above is of Mungo Lakes, where mum visited when she was in Australia.

Suma Ahenkro Girl’s Education Project, Ghana (2020)

In the latter years of mum’s life she had glaucoma, osteoporosis Parkinson’s disease and heart failure and was unable to leave the house. Despite this mum remained independent and lived on her own, with carers visiting. This continued until a couple of years before she died, when she had a live-in carer.

For the final months of mum’s life she was cared for by Belinda Comfort Damoah. Belinda stayed with mum for six months, throughout the covid-19 epidemic, and is held in high esteem by mum, all the family and friends.

I was able to spend the final 12 weeks of mum’s life helping look after her at home, where she passed away in July 2020.

Belinda has recently spearheaded the formation of the Akwaama Toprefo Female Club (ATOFEC) which has the education of young women and the skills training of women as it’s objective.

We collected for this project at mum’s funeral, and the family is proud to be linked with such a worthwhile endeavor. Mum’s picture now hangs on the wall of the schoolroom.

Written by Steve Turner Version dated: 14.12.2020

Revisions: Picture of Bull Hill, Stafford added. 25.01.2021


Thanks to Melanie Williamson, Collections Assistant, Staffordshire Archives and Heritage, Staffordshire County Council for finding the shield and providing pictures and information.
Website: http://www.staffordshire.gov.uk/archives
Facebook: http://www.facebook.com/StaffordshireArchivesandHeritage
Twitter: http://www.twitter.com/@ArchandHeritage

Having a plan – a short guide for patients

Steve Turner

Following on from my blog on making the most of remote consultations, I realised it would be helpful to talk about the outcome patients should expect from consultations (wherever they are conducted). This blog is based on my clinical experience, on feedback from patients, carers and relatives, and on my experience of helping look after my mother at the end of her life.

There are some simple things that everyone should come away with at the end of a consultation. Knowing the plan & what the next steps are. Where to find information on what has been discussed and what to do if things get worse. If this information isn’t made clear, ask ‘what’s the plan?’

Consultation information:

At the end of the consultation you must:

  1. Have agreed a plan (even if this is ‘watch and wait’, or a referral on)
  2. Have written information on what has been discussed & where to find support
  3. Know the signs of improvement or the signs of deterioration to look for
  4. Know when & who to contact if things change
  5. Know who to contact in an emergency

At the end of the consultation:

At the end of the consultation, you should know:

  1. That your concerns have been listened to
  2. That the agreed actions will be taken
  3. That you can seek a second opinion if needed
  4. That the consultation will be communicated to all involved in the patient’s care

You should also receive:

Written information on the consultation. This may be in the form of notes, a care plan or visit summary & copies of ALL communication between clinicians.

‘No decision about me without me.’

‘If you’re not provided your records (as you should be) , you may wish to keep a record of your consultations yourself and / or record them. As a clinician I encourage this.’ – Steve Turner RGN; RMN; Ba(Hons); P.G. Dip. Ed

In my next blog I’ll look at communication and documentation. What form should this take? Covering all options including: online access to records, patient held notes, visit summaries, assessment letters, patient notebooks, body maps, recordings, images. How can we ensure patients & all involved have this information in real time?

Previous blogs in this series:

A guide for patients on remote clinical consultations

Giving a history – guide for patients

Steve Turner

I am now retired and writing on what I learned about patient-led care.

‘Putting patients in charge of their care, sharing information, learning together’

📹youtube.com/@SteveTurnerCareRightNow

_______________________________________

Author: Steve Turner

Date last updated: 06.03.2023

Sharing your medical history with clinicians

Steve Turner

It is often assumed that the person carrying out a consultation has access to your medical records and your full medical history. Sometimes telephone consultations are carried out with a clinician who doesn’t know (or have access to) your medical history.

This is quite common. As we get older and are likely to have more than one medical problem (‘multimorbidity’ in jargon), and services are frequently delivered by different specialists from a variety of different professions (‘sub-specialisation‘ in jargon).

If we have a medical condition that has been ongoing for many years and is well controlled, we may forget to tell the clinician. You may forget to mention something like asthma for example, because it hasn’t been problematic for a while. It’s really important not to miss these areas, as the safety and effectiveness of your treatment plan depends on it.

It may help, before the consultation, to write a list of:

  • Previous illnesses, including mental health problems*, sleep problems and mood variations (‘no health without mental health’)
  • Previous hospital admissions & operations
  • All your long term conditions (the chart below shows an acronym ‘MJTHREADS’ used by clinicians). Alternatively it may be helpful to think of a ‘systems review’ in terms of a ‘body scan’, starting with the head.
  • All health related people (including complementary therapists, & support groups ) that you see.

In addition some (or all) of the following details will be relevant. Think about:

  • Your preferences and beliefs about treatments, including resuscitation & end of life care (often called advanced decisions or advance care plans)
  • Who cares for you or who you care for. People don’t always realise (or tell clinicians) that they are caring for others
  • Your job or lack of a job , or how you occupy your time
  • Financial worries
  • Your social circumstances – who do you live with? -do you have close family & friends? -do you feel isolated? -live in a remote location? – do you feel vulnerable? – your hobbies?
  • How you feel about your own safety – have you ever felt like harming yourself?
  • Past (or recent / ongoing) trauma and abuse
  • Your spiritual beliefs
  • Recent travel abroad
  • Your ethnicity
  • Your diet and any recent changes
  • Recent weight loss or weight gain
  • How much exercise you take
  • Your sleep pattern and any recent changes
  • Your family history
  • Other areas (listed here in no specific order) such as childhood history, pregnancy history, risk taking history or sexual history

*In response to feedback on this blog from patients, it’s important to note that there may be some details related to mental health that patients do not want to share with all clinicians.

The above list may look daunting, and is obviously not all needed in all consultations, however it’s worth reviewing. I have come across people who were waiting to be asked some of the above questions, and wanted to tell someone something important, who told me they only opened up because they were asked.

Your medical history:

Steve Turner is a nurse prescriber and clinical educator & Associate Lecturer at Plymouth University.

More here: https://linktr.ee/stevemedgov

Click here for the Care Right Now CIC web site

If you have any questions about coordinating care for a loved one, you can contact Steve by email: steve@carerightnow.co.uk

Published: 01.05.2020

Author: Steve Turner

Version: Draft 1c 07.06.2020

Version Draft 1d: 25.01.2021

Revision history: Asterisked note on patients’ preferneces for data sharing inclided.

Making the most of remote consultations – a guide for patients (*rolling blog)

Steve Turner

It is increasingly common for clinicians to carry out consultations with patients over the ‘phone or on the internet.

If you have time to prepare for the consultation here are some suggestions. This is part of our patient led clinical education work. The aim being to help all patients / users of health and care services lead on their own care.

In some cases, you may be talking to someone who has never met you, so preparation is key.

Here is some general advice:

Preparation

  1. Write it all down beforehand if you can, as it’s difficult to remember otherwise.
  2. Take some observations if you are able. Temperature blood pressure heart rate other measurements, including your feelings, mood and areas such as sleep & appetite. If the problem is something visible (like a rash for example) send pictures & monitor changes over time.
  3. Tell them how you are different from your norm.
  4. Tell your story of why you are calling, in your own words.
  5. Be honest and remember mental health and physical health are equally important. Inseparable in fact.
  6. Ask if you don’t understand anything.
  7. Don’t be afraid to check that the clinician has followed what you are saying.

It’s important that you are allowed time at the outset to tell your story in your own words, to be able to share your ideas, your concerns and what you are expecting for the consultation. If you are speaking to someone who doesn’t have access to your medical history, they will also go through this with you in detail.

This checklist will help you prepare for the consultation and lead to an agreed plan for what to do next. Think particularly about what you would like to have happen. This is a question you may well be asked.

A screenshot of a cell phone Description automatically generated

Your clinician will also need to refer to your medical history. If they have this to hand they may check that it’s up to date with you. Often they may not have this information and will have to go through your history with you. This is vital in order to ensure you come up with an appropriate and safe plan for your care. Click here for a second short blog on giving a history.

Medicines and treatments (of any kind)

Consultations often involve medicines and treatments. Because of this it’s important that you share details of all medicines and related substances you take, not just those that are prescribed. This includes herbal medicines, over the counter medicines, supplements and anything borrowed or bought over the internet. It’s vital to be honest, as interactions can be very serious, sometimes fatal. Your clinician will not think badly of you if, for example, you don’t take a prescribed medicine or are trying something else. Statistics show that at least 50% of people don’t take their medicines as prescribed. That’s 50% of the whole population with mental or physical illnesses, not just a specific group of people.

Remember a medicine isn’t always the answer, share with the clinician details of non-medicine related treatments and approaches you take, and how well this works.

This chart shows the information you need to share. Very importantly this includes details of any allergies or sensitivities and how these affected you.

What happens next – The plan

Finally, many consultations do not result in a medicine, or specific treatment, being prescribed. Some may result in a medicine or treatment being stopped, changed or reduced. Sometimes it’s a case of ‘watch and wait’. The most important thing is that both the patient and clinicians have agreed on plan, know how to monitor progress and what to do if things change.

What’s important is that:

  1. You have agreed a plan
  2. You know what tests are needed (if any) and they are arranged
  3. You know what referrals have been made and when to expect to have these consultations
  4. You know the signs of improvement or the signs of deteriorations to look for
  5. You have information on the problem and access to more in a format you prefer
  6. You know when & who to contact if things deteriorate
  7. You know the signs to look out for and when to call 999
  8. Everyone involved in your care shares this information

Summarised in the chart below:

*This is a rolling blog. I welcome all suggestions for amendments, deletions and additions from everyone. Please email steve@carerightnow.co.uk

I am grateful to my friends and colleagues who helped me put together this information.

Steve Turner is a nurse prescriber, now retired, & former Associate Lecturer at Plymouth University. Steve shares health information from the Twitter account @MedicineGovSte using hashtags: #TeamPatient #TeamNHS Author: Steve Turner

Version: 1

Revision History:

30.06.2022 – Changed to reflect that the author is now retired.

27.04.2020 – added a note about taking and sending pictures (‘Preparation’ point 2.)