Panel discussion and Q&A session XII: Evidence Based Medicine

Dr. Dror Dicker, Prof. Małgorzata Nowaczyk, Prof. Martin Härter, Prof. Roman Jaeschke, Prof. Gordon Guyatt, Prof. Victor Montori

Recorded at the 6th McMaster International Review Course in Internal Medicine.
All lectures available at the MIRCIM virtual platform, click here to buy access.

Dr. Dror Dicker: Good afternoon and good morning to everyone. My name is Dror Dicker, I am the head of the Internal Medicine Department of the Obesity Clinic in Rabin Medical Center, Tel Aviv University. I want to welcome all of you to this Q&A session on evidence-based medicine. I am also the president of the European Federation of Internal Medicine and the European Federation of Internal Medicine is a federation of more than 35 countries and more than 50,000 physicians around Europe. One of our main objectives is to promote the knowledge of education in all the fields of internal medicine, so we really see this opportunity to cooperate with MIRCIM as a great opportunity to promote the knowledge of internal medicine. Before we start, I really want to thank Prof. Piotr Wędziewski, who [invited] us to participate in this wonderful initiative, and all the organizers and all the people; we really thank the contribution from McMaster and all the other organizations. It is really my pleasure and honor to invite my co-chair, Prof. Guyatt, to really co-chair in this session. We also have Prof. Victor Montori from the Mayo Clinic from the [United] States, Prof. Martin Härter from the University Medical Center in Hamburg-Eppendorf, Germany, Prof. Roman Jaeschke from McMaster University, Canada, and Prof. Małgorzata Nowaczyk from McMaster University, Canada. So thank you to all the panelists. And we will start with you, Professor Guyatt, for the first question; so I will read the first question. Professor Guyatt, “you search for what is important to patients. However, how [can you] avoid mixing it with what is important to you as a physician?”

Professor Gordon Guyatt: Well, you have to… hopefully, as physicians, we engage in shared decision-making. And in shared decision-making, we try to make sure that we involve the patients and find out what's important to them. So, just the story of my… And one of the things we get is [that] patients say to you, “what would you do, doctor? What do you recommend? What would you do for your spouse or a relative?” And I had a patient who had a gastrointestinal bleed. We couldn't figure out why, what the source of the bleeding was. But they were receiving anticoagulants for atrial fibrillation. And the patient was CHADS 4, quite high-risk for stroke, for the atrial fibrillation. And the question came – the patient was ready to leave the hospital – do we renew the anticoagulation now or do we renew it later or perhaps not at all? And the patient asked, “what would you do, doctor?” I said, “what I would do – I am very frightened of stroke myself, terribly frightened of stroke. Strokes have long-term consequences and bleeding can be awful, but bleeding we can treat. You've actually just been through a bleed, you know what it's like. Stroke – you don't know what it's like; you don't want to know what it's like. But it depends how worried or frightened you are about the stroke or how worried or frightened you are about the bleeding. If it were me, I would start on anticoagulants right now because I am terrified of stroke.” The patient said, “I see your point. I am terribly frightened of stroke, too. I will re-start my anticoagulants now.” So the point being, [if] a patient asks you what you would do, you could [tell them] what you would do, but then you share your values and preferences and make sure they are consistent with those of the patient.

Dror Dicker: OK, thank you. So, the next question is for Prof. Härter. “How [should we] deal with a situation when some patients are better informed about a specific management issue than [the] clinician?” This may happen especially in primary practice where a clinician cannot be an expert in everything.

Professor Martin Härter: Yes, thank you very much for this question. Just [about] my background: you said I'm from Hamburg – that's correct, I'm a medical psychologist. So I am very focused on teaching physicians from very different disciplines – many oncologists, internal medicine doctors, [and] primary care physicians – how to deal with these shared decision-making issues. And clearly, it happens and it's true that some patients come with a bunch of information and that they really are experts in questions. I would recommend to colleagues to be as open as you can, just to say, “oh, you are more expert than me, so please tell me about the knowledge you have.” So it could be an exchange from the other point of view, because I think the very important thing here is [that] it might seem that this patient is better informed, but it's better if you are checking what kind of information the patient is bringing in. This is often [a problem that we see], because many patients have these Internet downloads now or this false or misinformation, so it's really good to check. But at this point, the question is really raising the point [that] a primary care physician might not be the best expert, and I would say that that's OK. It can happen that the primary care physician is not an expert in each field. So just to say, this could happen, it could be one strategy of helping the patient to open what he knows and then to start a discussion. And it could be, [as] Gordon was saying – it's a little bit the opposite – so “what would you recommend?” So the patient can, as an expert, enter the discussion with the doctor and then they will find a way [of dealing] with this problem. That's maybe one solution. Another solution could be… it depends a little bit on the clinical problem. If it's really a difficult problem, clearly a primary care physician would say, “it might be better to have a second opinion on that because I'm not an expert here, so please go to a colleague or I could help you to find a colleague to discuss this problem [and] find the best solution for you.” This could be another strategy.

Dror Dicker: I think another question that relates to this question is [that] a lot of people come with the Google medicine and show you some studies from Google. And you really don't believe this [but] you have difficulties really confronting the patient. So how can you do it in a way that would not offend the patient?

Martin Härter: Yes. Well, now we are, let's say, in a better situation, because hopefully for many of the clinical situations, we can have access to so-called decision aids or decision tools, where the literature, the evidence base in different clinical situations is [already], let's say, well-designed in information sheets or grids or whatever. So you might use this kind of information to discuss the pros and cons of different options because to focus just on single studies is always not a good idea. But again, I would say if this is important information and the patient is saying, “oh, look doctor, here I have this study,” you have to frame this study into the clinical context, [to decide whether] the study really fits with the clinical question that the patient is raising. But on the other hand, you might [find] help with this kind of decision tools. There are libraries. I could maybe put into the chat, if people are interested, how to find this kind of decision tools that give you a way to deal with this problem.

Dror Dicker: Yes, I think it's very important because it's very, very often that we are dealing with this problem. So thank you. So I see that Prof. Montori joined us; I want to ask him – Prof. Montori, you are with us – so this question relates to care: “Have we lost the incentive and ability to care?”

Professor Victor Montori: Well, caring is a profoundly common human activity. I don't think we lose it, but we are certainly in a world at the moment where we have a crisis of caring and we have a crisis of trust. And some of that is real, and some of that is the impression that we get from the consumption of the information that we receive. So we are all immersed in large amounts of information that comes through social media environments that have algorithms that highlight negative stories, [which] have the ability to be transmitted much more effectively than those moments of care that perhaps are not so exciting and not so dramatic, [and are] set aside. So what we get is the impression that we live in a careless world, in a world in which we cannot trust anybody. Yet I think every day, mothers take care of their babies, children take care of their parents, parents take care of their children, neighbors take care of each other – and it's just not news, but it's who we are as human beings. And we try to take care of the environment around us; we try to take care of our community. And I think what makes it a crisis is that we're not celebrating that enough, that we are not highlighting that enough. And in healthcare, I think where we find ourselves is sort of at the professional tip of that practice, you know, where we ought to take care of our patients in a professional way, with compassion and competence. Now, our healthcare organizations – you know, I think COVID-19 has made this pretty dramatic – many of our healthcare organizations have failed to take care of its professional caregivers. And caregivers have found themselves taking care of patients without necessary equipment to protect themselves; they have found themselves showing up to care even after they've been emotionally traumatized or burned out. So I think there are opportunities to improve the way we care for our patients by improving the way we take care of our caregivers, professional and informal caregivers – how we take care of each other. So there is a crisis of care, [but] there is a huge reservoir of caring in our humanity and we just have to make sure that healthcare doesn't move forward without it.

Dror Dicker: So, if I understand you correctly, you suggest not to put just the patient in the center, rather to put the caregiver and the patient in the center. And this will allow us to really fit the patient and his caregiver into the center of our practice.

Victor Montori: Yes. I think caring is what ought to be happening in healthcare, right? I mean, we have all the systems and all these technologies and all this development, but what's at the center of it is our ability to notice and respond. That should be the main activity and everything else needs to be designed to support that activity. And that activity can only be done by human beings in proximity, so we need to make sure that we don't fall into the trap of pursuit of efficiency and other things, you know, [to] think that data can care or that technology can care. There is a certain rhythm and nature of care that requires a connection that is not just intellectual or evidence-focused, but it's in fact also about values, also about goals, also about feelings, also about emotion. The situations that we care for people [in] are confusing and confused because of all those factors. And I think it's something that humans can do with brain and heart, not at the speed of light as technology might invite us to do, but at the speed of trust.

Dror Dicker: OK. Prof. Jaeschke, I think we have a question similar to the point that we just discussed. So, “how do you find the time for conversation and caring?” For instance, in my country, in Israel, we have less than 7 minutes in the primary physician clinic to deal [with] or to treat the patient. Less than 7 minutes. So, how do we find the time for conversation and caring? Prof. Jaeschke?

Martin Härter: Oh, it was for me, sorry. Or for whom was the question? For me? Well, that's an average. I think in Israel it's the same as in Germany: we have 8 minutes, but it's an average. So, sometimes you have a person who just needs drugs, so it's a minute; but it's clear. And 8 minutes seems short, but what we have seen when we have taken audio tapes of consultations, when we have trained doctors, [is that] they can care and they can do shared decision-making also in 8 minutes. It depends a little bit, clearly, on the clinical problem, but I think this is one of the major arguments always raised: we don't have the time. And we have seen studies and there are [] studies showing [that] people who are trained in communication skills do not need longer times; they are more focused and more structured in their consultation style. And that's the important message: don't worry too much about the time. Take the time and tell the patients, “so we have 8 minutes. Let's focus on the problem you have. I will be with you and I will take care of you and your problems, and let's see. And if it's not enough, we'll have to postpone and we'll need another consultation.” I hope that helps.

Dror Dicker: Prof. Nowaczyk, there is a question for you as well: “The system these days rewards speed and efficiency. How prevalent is the concept of narrative medicine in your own clinical environment?”

Professor Małgorzata Nowaczyk: Thank you for this question. I do something a little bit different than internists do. I am a clinical geneticist and I spend a lot more time with my patients, so I do have the luxury of time. But I did want to address the previous questions – previous answers, actually – from Prof. Härter and Prof. Montori. Prof. Härter said that if you have appropriate training before meeting a patient, being more attentive and paying attention to the non-verbal cues – and verbal cues – will be so much easier. Narrative medicine, the way that I practiced it, is not something that you do there at the moment with the patient, but something that you train for with reading literature, with writing, with keeping a different style of a patient's chart. And those things that you do outside of clinic are the ones that prepare you for better noticing – as better responding, as Prof. Montori said – because it is the noticing – as he has so importantly pointed out, too – that is the most important thing in the patient–physician interaction. And narrative medicine, the training for it, does not happen in the clinic. But once you're trained in it, it will become a second nature, the narrative lens of looking at a patient's story and getting more information out of the patient's story, and then becoming more empowered to attend to that patient's needs and to act on those needs will become a second nature. It will become almost automatic – although we don't want it to be completely automatic – it will become second nature… and will actually, sorry, in the end, save you time because you will not have to see the patient 3 or 4 times [going on] a diagnostic odyssey, trying to figure [it] out, because you will have the clues and the information from the patient, hopefully from the very beginning, from your first interaction with the patient. So in the end, doing the work outside of clinic saves you time while in clinic.

Dror Dicker: OK, thank you very much. Prof. Jaeschke, we have another question for you. Can you hear me, Prof. Jaeschke?

Professor Roman Jaeschke: Yes, very well.

Dror Dicker: Great. So what [should we] do if empathy and caring compete with requirements like rules and laws of modern medicine?

Roman Jaeschke: Well, it obviously depends what we consider modern medicine and I suspect some of the previous answers were touching on it, thinking about speed, efficiency, and maybe… Obviously the question with efficiency is what do you want to achieve at the end?… whose needs do you want to meet? I would answer this question one way: We are probably all at the stage where either we ourselves or our family members are patients, are not only providers, but consumers. And I would argue that it's fairly clear what is important to us. Frequently, I get the impression, including myself, that you need both, because if you get only one, you are absolutely incomplete. So I would argue you cannot… I wanted to say originally [that] I want the empathy and caring more than I want even professionalism and advice, but once I thought about it, I probably need both – for my quality of life, for my trust in the system, for my trust in the providers. This first psychological element, if you wish, is crucial and you cannot sacrifice one for the other. Again, the needs of people are different: some of them are technically [minded] – engineers, if you wish – [and] they just want information; some of them need something different, and again, you will need to figure it out within those 8 minutes, or hopefully more. You know, in intensive care, I spend sometimes hours with a single patient and their families and I try to figure [it] out, putting myself in the shoes, so the speak, of both patients and family members. Sometimes who is important changes in all of this, but clearly, the clinician is less important than those to whom you are delivering care. So try to avoid this conflict as much as you can and keep in mind the caring part.

Dror Dicker: OK, thank you. So I have a question and I will be very thankful if you could relate to the question. So what I see in the young generation in my department, and I assume that it's in everywhere in the world, [is] that we are touching computers and iPads and iPhones much more and touching the patient much less. So we become much more technological and much more sensitive in caring. What is your opinion or advice [on] how to really teach the young generation or the residents or ourselves to really touch the patient more and the computers much less?

Victor Montori: I can try to take that, Dror. I think that's a very good question. I want to first point out that many of the things we do when we touch patients have purposes that may or may not be evidence-based, right? So there are parts of the physical exam, for example, that perhaps people do routinely, but they are not as good as we thought initially or we have better methods now to uncover the problems that those examination skills were developed for. So there are some forms of touching that might be ineffective and therefore inefficient, leaving room for other things. There are forms of touching that appear to have no diagnostic role, but they are therapeutic and they create points of connection, physical connection you said, with people. I have an observation which I believe is fairly common, but I think is poorly explained. During COVID-19, we moved a big chunk of our practice to a telemedicine practice, where physical contact is impossible, you know, the best we can do is pretend… to see each other eye to eye but it's off, you know; the screen is not right and so forth and the other person is either huge or really small and it's really awkward. At the end of a clinic day filled with patients in a telemedicine practice, I [am] completely exhausted. At the end of a clinic day when my patients are in the same room and there is interaction that includes touching, but also includes real looking into people's eyes and micro-expressions of emotion, silence as warmth – all these things that we're very skilled as humans at, to communicate or fail to communicate – I usually feel energized. And again, I think it's a common observation. I think we need to have some understanding of why it is, that effort at connection. My metaphor is, you know, like when you go with your phone to an area that doesn't have coverage and your phone is constantly trying to look for the antenna to connect and then your battery drains [from] the effort [of] constantly trying to look for a connection – that's my metaphor of trying to connect with people when they are not in the room. I struggle for connection. And you get illusion; perhaps you did it but it's unclear. The other thing is, in terms of how you teach the younger generation, I think we teach them the same way we taught them everything, you know, by role modelling. And so – I'm a diabetes doctor – I supervise clinicians that are rotating through the diabetes service and oftentimes these are consultations that appear to be very much technical problem-solving, but behind the person that has poorly controlled diabetes, there is a whole life in which the mess of diabetes is just the reflection of what else is going on in their life, which is often what is challenging. And some of the interactions I have with those patients end up exploring those issues in-depth. And my trainees get upset that I'm taking too much time and invariably the patient will cry and that's going to set us back in the schedule and all these other things. Nonetheless, I do it because it is often those moments of deep human connection that the real problem behind the problem emerges and the opportunity to potentially solve problems that are real begins to appear. And it just takes one moment to demonstrate that magic for people to remember that that's why they went into healthcare in the first place.

Dror Dicker: Yes. I really absolutely agree. I just finished leading the isolation COVID-19 department for the last 12 months. In the beginning, we as senior physicians and the residents, really treated the patients virtually because they were very non-severe COVID-19 patients. And we felt very, very peculiar because we didn't touch them and the history taking was virtual and it was very new to us. We really felt exactly like you described – very exhausted. After a while, when the more severe patients came and we had to get into the department, stay in the department for long hours, we started to touch the patients and examine the patients – so we returned to the basic internal medicine habits. And I think now, when we finish this term, we really understand the importance of touching and caring for the patient, not with masks anymore, not behind screens anymore. And I think this is one of the good things that came out of COVID-19: that we really appreciate the humanity and the connection and the touching of patients and understanding of patients, not just standing behind computers and clinical records. So any other thoughts from the panelists? Yes, please.

Roman Jaeschke: I wanted to reinforce it. Unfortunately… before COVID-19, I had a rule which I forced the residents to [follow] in intensive care, where their tendency to look at the computer is probably the largest. The first rule of looking after patients was “touch your patient every day.” And I said, “I don't care what part of the patient you touch,” but it was forcing people to look at the patients… And even looking inside the room from outside, you know, when you look at how people stand on rounds, a lot of them have their backs to the room with the patient. You cannot see it. So just touch your patient every day or you failed the rotation. Maybe it's a little draconian, but it was expressed. Now, COVID-19 made it difficult at the moment, but I hope we'll go to “wash your hands and touch your patients every day.”

Victor Montori: Yes, it's a very good slogan.

Martin Härter: Just to add, I think you also raised the question [of] how to handle the challenge between “we need these computers, we need the smartphones, the guidelines [are] on the smartphone” and how to have a habit of “OK, here's the patient so I won't use the cellphone or the computer now.” But it has to be focused. When you need it, you might frame it as “oh, let's look on the computer” or “I have to check something,” just to frame it in a different way, not as we also do it privately. We see it when we are at private parties, so many people are really misbehaving with the smartphones. We know that. So I think it's also a professional attitude, when we need the computer. So use it, but explain it and use also other times where you look into the eyes or touch patients, as you said. And what we are doing [when] training – and that's important – when we are training medical students mostly, but then we are focusing only on the patient or simulated patient or whatever, but they are only people so we don't have any technical assistance. So the communication, the speaking, the verbal [and] the nonverbal cues are the only source – the story, as Małgorzata said. So the narratives of the patient are important. Just to learn how to normally talk to humans. So that's also very important.

Dror Dicker: Yes, I absolutely agree. So Prof. Guyatt, can you take the charge and ask the next question, please?

Gordon Guyatt: Prof. Dicker, you are doing such a good job, alternating between people [and] picking up the questions. I could not do as well, so I suggest strongly that you continue.

Dror Dicker: OK. So can I ask you a question?

Roman Jaeschke: Punish him.

Dror Dicker: No, no, absolutely not. The question is, “were considerations of what you are talking about present in evidence-based medicine from the beginning? Or have they been incorporated with the evaluation of evidence-based medicine?” Did they change, your perceptions of evidence-based medicine [over the] years?

Gordon Guyatt: There has been a dramatic change in evidence-based medicine since the beginning, related to the issues that we are talking about here, and that has been the enormous emphasis on values and preferences. If you look at the article, the first JAMA publication in 1992, that was the flagship shot across the bow of evidence-based medicine, you will find no reference whatsoever to values and preferences – or very minimal. When we were starting it, that was not at all our focus. And what happened is that as we were lying out and having people pay attention to the evidence and really focusing on that, it became very evident that in almost every decision, there were trade-offs to be made. You had the best evidence about the benefits and the best evidence about the harms, and where do you go from there? And fortunately, it didn't take too long before we developed what became our first 2 principles of evidence-based medicine, where some evidence is more trustworthy than others and we need systematic reviews of all the best evidence to inform our decisions. And then we developed the third, somewhat ironic principle of evidence-based medicine, which is “evidence itself never tells you what to do; it's evidence in the context of values and preferences.” And the critiques of evidence-based medicine and the article in 2000, in which we introduced this third principle of evidence-based medicine – it's over 20 years ago now and a lot of people still don't seem to have heard us. And so, I'm thrilled that this session on evidence-based medicine has almost no reference whatsoever to all the things, the stereotypes of evidence-based medicine. It seems to be absent here from this session, which I think is great, that maybe people will finally get the message that the values and preferences, that evidence by itself never makes the decision. It's always evidence in the context of values and preferences. And as soon as you say that, the focus becomes on the patient. And there were earlier questions about the expertise. One way of looking at it that – I think, Victor, you may have come out with it initially, I'm not absolutely sure – [is] that we are hopefully experts in the evidence in terms of the benefits and the harms and the patient is the expert in terms of the patient's values and preferences. And I think that's a nice way of looking at it. So that yes, it was not the focus at the beginning. I'm pleased to say that we got the message less than 10 years after we started and we've had the message for well over 20 years. And anybody listening to this session about evidence-based medicine has to get it that the patient and the patient's concerns and relating to the patient and the patient's values and preferences are at the core of evidence-based medicine.

Dror Dicker: Great. Thank you for this excellent answer. I think the next question is related to this and I really ask everyone to relate to the answer because it's very relevant: “In Canada and possibly elsewhere, there is widespread advice to discuss COVID-19 vaccination with your family doctor, which means shared decision-making in a situation of uncertainty and competing, conflicting information. How [do you] conduct yourself as a clinician if you have limited information, even if you find the time to look for it?” I think it's a crucial question these days. So, please.

Martin Härter: I miss that surely. I think what I have seen in the… Well, we have seen it all in the last year, it was clear. At the beginning it was really a very tough situation of uncertainty, also when we started the first clinical trials with the vaccination, but now we have, I think, a solid basis for this kind of talking to people about vaccination because we have fact sheets; in different countries they have been developed, [discussing] the pros and cons of vaccination and so on. This would be the right way to do it. I think that the major question here is, from a population perspective, it might be a different perspective, looking to the individual perspective. So some people would say, “I don't want to be vaccinated” and we know from the population's perspective it might be not a good decision. So there is the trade-off between the interest of the society and the interest of the individual. But I think to talk about the potential risks and benefits of vaccination, we have the data already to show the patients and they are quite evident. I think, I'm not sure what my colleagues are saying, but in Germany we are now using a fact sheet which has been developed with our center of risk communication and the Quinton Centre in the UK has developed some of these materials. I think they are really helpful.

Victor Montori: I have an add-on to that. When the vaccines became available, there were people dying to get their hands on them and get them. And I think in many places that group of people, if they have had access – I mean, we have to remember that much of the world is still waiting for the vaccines to arrive, but in places where the vaccines have arrived and have become available – a very large number, a majority of people have gotten vaccinated. And there is a minority of people that remain not vaccinated. And the question is why? I think one of the first things we have to do when we are in this is to seek to understand. What is driving either their lack of interest – is it apathy, is this hesitancy, you know, are they not sure [if] there is a conflict between something? In many cases it's lack of trust. You know, for decades we have seen pharmaceutical companies behaving quite poorly and all of a sudden now we have to trust that what they put in front of us is safe and effective. And of course, in record time, with perhaps what we think might be not the, you know, substantial oversight and so forth. And people who have been hurt by these problems in the past might be now in the camp of people who'd rather, you know, wait. I mean, I am for instance a very conservative prescriber; I'd rather have the patients of other doctors experience a side effect of the new drugs than expose my patients to them, right? And so this is a significant challenge for me because in this case you have to be an early adopter in order to protect your patients from such a significant threat. And then you have the other problem, which is what I think Martin was referring to very eloquently, that vaccinations in general are not usually clinical decisions. They are usually public health interventions that work, in part, not just by protecting each person that gets vaccinated, but by creating a shield around the community so that the virus, in this case, cannot enter that community and affect the most vulnerable in it. And we have, to some extent, lost our narrative of solidarity, of caring for and about each other. So when we put forward that the argument is individual protection – in the United States, the CDC has come out saying, “your health is in your hands. Get vaccinated” – Well, that suggests that my only responsibility is for myself. So we have completely lost the public health narrative that the reason we do some things is because we are to care for and about each other. And I think that is very costly when it comes to public health interventions such as vaccinations.

Dror Dicker: Anyone to… Sorry, yes, please.

Gordon Guyatt: Just a question. When you started with that question, the issue was [that] the knowledge is there but we don't have it or the knowledge isn't there. I presume it's the latter that you are talking about in these situations. Well, that's true in at least 50% or maybe more than 50% of the decisions I'm helping my patients with. It is a very common, if not ubiquitous situation, where the knowledge is – at the very least – incomplete. And we're dealing with uncertainty all the time. At the beginning, I think that was [part] of the resistance to evidence-based medicine, [that] it was pointing out how frequently we don't know, we know very little, or at least we don't know anywhere near… we don't have the confidence that we'd like in our decision. And that's one of the key messages for evidence-based medicine: to be aware [of] and get comfortable with the uncertainty. And that bears on… and emphasizing that… one example from the past was what clinicians did with hormone replacement therapy. You remember, there was a time when every woman was persuaded to use hormone replacement therapy because surely it lowered cardiovascular risk substantially, on the basis of the observational studies. Well… the approach that EBM [evidence-based medicine] would have taken then was to say, “but actually… maybe, maybe it's going to reduce your cardiovascular risk, but we are really very uncertain about the matter. So if you are going to use this, well, maybe you will want to… back to your values and preferences. Do you want to put yourself at the certain burden and risk of an intervention for uncertain benefits or not?” The bottom line is, EBM is always – COVID-19 or no COVID-19 – and as Martin pointed out maybe with respect to vaccines, we know much more than in many, many of our decisions, and acknowledging the uncertainty to ourselves and with our patients, is central to the exercise.

Victor Montori: I wonder if Dr. Nowaczyk has some thoughts about the stories? Because there is a tremendous amount of narrative that is being, you know, layered around the vaccines. And I wonder if the existence of negative narratives is contributing to some of the hesitancy or the apathy around it?

Małgorzata Nowaczyk: Yes. The narratives are so varied when it comes to COVID-19 and vaccination. And I think they started even before COVID-19. The narrative of, you know, side effects from other childhood vaccinations. But I think that the biggest narrative, which is, you know – it's so ridiculous that it even makes me feel uncomfortable to mention it – is that, you know, I don't know if you heard the narrative [that] there is a chip in the Pfizer vaccine, right? And Bill Gates will be able to remotely… Yes, and 5G. But the other one, less ridiculous but still ridiculous from the medical point of view, is that it renders you infertile; this is something that I heard. And this is just showing you the power of the story. And you know, science can be saying one thing, but if somebody, you know, has a story and believes in the story, putting it in the context of patient's values and patient's beliefs, you have to struggle with something that's very powerful because stories are very powerful, whether it's the story of the illness [or] it's a story of being controlled by Big Pharma. They have to be taken into account, and just like Prof. Montori was saying, you know, I loved your story about making the diabetic patient cry, not because you are a mean person, but because it allows you to get at the bottom of the story and allows you to find out what else the patient is dealing with. And I think the same thing goes in the context of COVID-19. And again, it's a lot of work and [you] may not have the time for it at the vaccination clinic, but there may be a story that the patient has that if you address it, you may be able to get at it and then… I don't want to use the word “convince” because that's not the point of it, but maybe appreciate and understand where their beliefs are coming from and maybe address those and get at the bottom of it. But yes, there sure are lots of stories about COVID-19, very powerful ones. Thank you for the question.

Roman Jaeschke: Unfortunately, I believe, when people are telling the stories of what happened to them or what they know, they usually concentrate on negative stories rather than on positive stories. So we will not hear somebody saying, “Oh, I got vaccinated a month ago and that's why I'm not getting COVID-19.” You will hear, “I got vaccinated and that's why I got myocarditis” or something of this kind. And I want to comment on what Martin and Gordon were saying. Gordon, you've described the situation where we don't have good evidence. There are situations where we have good evidence, but we cannot comprehend it or summarize it on an individual basis. And that's where the evidence-based medicine, so to speak, can help: by creating those fact sheets about which you were talking. So every German physician or Israeli physician or Canadian physician will have this summarized information, telling you that, you know, you get thrombosis in 1 out of 50,000 versus if you have COVID-19, you get 1 in 10, for example. And there is the power in knowledge, but it's crucial that we prepare it for ourselves in areas of our own specialty.

Gordon Guyatt: And just with regard to that, Martin has already put up on the chat, I think, about the website of decision aids. And we have more and more good decision aids now. And in terms, fact sheets are one thing, but decision aids with, for instance, visual presentations of what 1 in 50,000 means [with] a set of 50,000 faces and the 1 face with the adverse effect, for instance. You know, because people have problems with numbers. Anyway, there are various things that the people making up decision aids have developed to help patients understand. So fact sheets are great; decision aids that take advantage of innovative approaches to present information to patients to enhance understanding are even better.

Victor Montori: I would want to highlight one aspect that is often misunderstood, I think, although it's not a very popular position. Our first approach to a patient that decides something that we don't agree with is that they are ignorant and that they must be educated and informed. And so, then we produce a lot of information materials because, of course, if they knew what we know, then they would make the same decisions we would make. And that of course simply ignores this issue of values and preferences and goals; it ignores the power of stories, that we've also heard about; and it oversimplifies the issue and invites us to tell, to talk, to give, when oftentimes the first step is to step back and listen and seek to understand. So, you know, yes, it's great to have accurate information for those for whom that is the missing piece, but let's not treat information as the main approach, when the main approach may actually be to take a more caring, listening approach [and] to seek to understand the person. Now, having said that, I have to tell you that one of my sisters has taken on this anti-vaccine approach, and as you were talking about the 5G and the chip and all that – I get that in my family e-mails, you know, routinely. And so at one point, my mom, who is 80, needed to be vaccinated. She is in Peru, that's where I'm from, and Peru is having one of the worst mortality situations in the world, so I wanted to protect my mom. So I flew down there, grabbed my mother, and brought her to the United States so that she could be vaccinated, taking full advantage of my privilege. And my mom resisted the vaccine and eventually I brought her in and said, “no, you are getting the vaccine.” So I tried to listen and understand and eventually brought her in to the place where she could get vaccinated. And she got the vaccine and walked out and was so happy that she finally got it. Only 2 days later she called me on the phone and said, “Doctor Fauci just told me I'm going to die of a clot in my head.” So we had to address that issue after that happened. But the bottom line is sometimes as clinicians we just have to be the clinician our patients need us to be and go from information or discussion and understanding all the way to persuasion, and in the case of my mom – coercion.

Małgorzata Nowaczyk: Of course.

Gordon Guyatt: So with regard to that, I like an example of the fact that there are different types of rationality. So, for instance, to take this one, your chances are only 1 in 50,000 of having this bad thing happen. And the patient answers, “doctor, you don't have my lived experience. My lived experience is [that] if there is 1 in 50,000 that are going to have the bad thing, it's going to be me.” And that is one [way] of looking at it. There is nothing irrational about that.

Dror Dicker: Yes. Wait until you start to vaccinate children and then you will see the narrative stories. You can't really imagine what happens here with the vaccination of children, so I won't open this case. I want to finish with a question for you, Prof. Guyatt. And this question goes like this: “You usually talk about bias number needed to treat in confidence interval. How important [is this], in comparison [with] what you talked about in your lecture?”

Gordon Guyatt: Well, what this reminds me of is Prof. Jaeschke's “thinking aloud” answer earlier. And if you remember, he said, “oh, as I started to ask the question I was thinking what would I prefer: the evidence-based technical competence or the caring?” And he said, “well, you know, I think I'd like the caring – that's more important.” And then he said, “wait a minute now. Now I'm not so sure.” It is a misguided approach to treat these things as “either/or”: they are both necessary. The evidence-based clinician will know the evidence and will also understand all the things. And I say again, it is wonderful for me to see a session titled evidence-based medicine that has been focused on the values and preferences and caring aspect of what is evidence-based medicine, but it is misguided to present them as “either/or.” They need to be integrated together and to practice medicine optimally we have to use them fully as much as possible in all our interactions with our patients.

Dror Dicker: Thank you. I see we have a few minutes left, so I want to refer the next question to Prof. Nowaczyk. “Is what you are talking about – careful listening, looking for nonverbal clues – something new or something previously presented but possibly lost?”

Małgorzata Nowaczyk: Thank you. Way back when, when I was a medical student, we had a course titled “Communication Skills,” and that's where we were taught some of these things. Basically, we were let loose on a bunch of unsuspecting patients who allowed us to practice on them. And then over the years, you acquire more skill with that. I think that these days, in the era of technologization and, you know, machinery and iPads and iPhones and everything, a lot of the interpersonal skills are lost, as we were saying earlier. But narrative medicine is not just that. Narrative medicine is teaching one to become more attentive by parsing the patient's story and becoming empowered to act on that story. It's a little bit more than what communication skills were back in the mid-1980s, but they come back to that and you still have to have good communication skills. But I think narrative medicine gives you just an added dimension to it, for an appreciation of the patient's story and the whole, you know, the whole experience that the patient brings to you because it teaches you to attend to not just the medical but the religious aspects, life experience aspects, family life aspects, psychological aspects – things that I was never taught or learned about at medical school. So yes, it's a little bit of the old that got lost, but there is also a new set of tools that are very helpful in bringing the attention and noticing back to clinic and our technological knowledge.

Dror Dicker: Thank you. So, to finish, I want to ask all of you a very, I think, important question. “How can we really teach caring?”

Gordon Guyatt: Well, I would say that Victor had the right answer to that one, which is role modelling. I believe that we are the physicians we are because of the more powerful role models that we have seen. We see in our… Training as a physician is an apprenticeship experience. And there we work with all sorts of different physicians and we say “these are the people who we would like to emulate.” And as much as possible, we become these physicians as we try to emulate those who we think have done the best job. And I think Victor's story in that regard was very compelling: Victor said role modelling is the way to do it. And role modelling is the way to do it. And I was heartened by Victor saying that he believes that learners are impatient, “let's get on,” that when they see someone make a connection, a special connection that they might not have seen with other role models, it makes an impression on them. And that what you need. This again, this also relates to the narrative issue. There are certain things that make emotional impressions on us. And if you are going to change people's behavior with short exposures, you need to make an emotional impression on them. But the way to get people to care is to show them caring. And I will say, it comes with Victor. Victor's been kind enough in the past to note when he saw certain types of caring about colleagues when he was working at McMaster that has motivated him, I think, in the rest of his life. When we see people care in a way that is special, that is how we teach them to care.

Martin Härter: Gordon, I absolutely agree. My question is – it's a very positive end and I'd agree – but do we have enough positive role models?

Gordon Guyatt: Let's train them so we get more.

Małgorzata Nowaczyk: And to all of that, I would add – role modelling is definitely the way to go, but I would also add to that – reading literary fiction and poetry, because it allows you this vicarious insight into other people's lives that popular fiction and other books do not give you, but you do get an emotional response while reading poetry. And it's kind of like a dry run training for dealing with people. So those who read are those who care a lot. Thank you.

Victor Montori: Some experiences of emotion come from living. Some of our younger colleagues haven't had an opportunity and so living through literature or art in general gives them an opportunity to respond appropriately by, you know, having additional experience than the ones that life has given them. So I think that I resonate with that recommendation. And also to add that medical schools and organizations, when they realize the potential scarcity of role models, Martin, they have to make sure that they direct traffic to those scarce role models, because what I think happens more often is that the teachers that have time to spend time with the trainees are the ones that are very efficient, which happen to be the ones who are not spending the necessary time and paying enough attention. So we have an unintended consequence of the efficiency of education, which is to expose students to the efficiency of healthcare [and] is not the elegance that we're trying to demonstrate.

Roman Jaeschke: As one of the organizers of this conference, I would like to ask you, in the new spirit of spreading the role modelling, we'll give you all the links to our whole discussion, unusual discussion on EBM and you could tweet them, Instagram them, whatever way you want to spread the good news.

Dror Dicker: Yes, Roman. I think it's an excellent idea and suggestion. And I really want to conclude our talk. I really felt inspired by the discussion. I am sure that we [are promoting] the knowledge and the skills of caring and evidence-based medicine of our listeners. And I really want to thank you for this wonderful Q&A and wonderful congress. Thank you, and I hope to meet all of you face-to-face next year.

Martin Härter: Hopefully. Thank you very much. Bye, bye.

Dror Dicker: Bye, bye. Thank you.

Co-financed by the Polish Ministry of Education and Science within the program „Doskonała Nauka”
(„Excellent Science”)

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