Medical ethics & evidence based medicine?

Medical ethics & evidence based medicine?

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  Dr.Shirish Kumthekar.Consulting SurgeonOncologist. Kumthekar Multispecialty Hospital & Rsearch Center. Main Road, Jule Solapur. Solapur. www.kumthekarhospital.com.
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  Ethics Definition:  Theword ethics is derived from the Greek word ethos, which means "character,“.  The most important element in ethical behavior is knowledge that actions are accomplished for the betterment of the common good of individual and society.  To put it formally ethics is the branch of philosophy that defines what is good for the individual and for society and establishes the nature of obligations, or duties, that people owe themselves and one another.
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  Medical Ethics  Medicalethics refers to the system of values common to medical profession and application of these values to practice of medicine. It is the standard of behavior by which physician evaluate their relationship with their patients , colleagues and society.
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  Principles of MedicalEthics Autonomy : Right to choose. Beneficence :In the best interest Confidentiality Do no harm/ Non-maleficence Equity or Justice
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  Ethical Codes  HippocraticOath – 5th century BC  Nuremberg Code -1948  Declaration of Geneva - 1948  Universal Declaration of Human Rights-1948  Helsinki Declaration -1964  International Code of Medical ethics  Indian Medical Council (Professional Conduct, Etiquettes and Ethics) Regulations, 2002
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  Hippocratic Oath  Oneof the earliest document in medical ethics – 5th century BC.  Traditionally all doctors recite this oath at swearing in. It is considered sacred for its religious foundation and sanctity.
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  Nuremberg Code -1948
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  Declaration of Geneva Adopted at World Medical Association General Assembly in 1948.  Amended in 1968, 1984, 1994, 2005 and 2006.  Declaration of physicians’ dedication to the humanitarian goals of medicine.
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  MCI Regulations -2002  The Medical Council of India notified the “Indian Medical Council (Professional Conduct, Etiquettes and Ethics) Regulations, 2002” on 11 March 2002.  Last amended in 2010.
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   Declaration- Each applicant,at the time of making an application for registration under the provisions of the Act, shall be provided a copy of the declaration and shall submit a duly signed Declaration.
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  Unethical Acts  Advertising Patent and Copy rights:  Running an open shop (Dispensing of Drugs and Appliances by Physicians)  Rebates and Commission  Secret Remedies  Human Rights  Euthanasia • Printing of self photograph, or any such material of publicity in the letter head or on sign board of the consulting room or any such clinical establishment shall be regarded as acts of self advertisement and unethical conduct on the part of the physician • Not endorse any items Formal announcement in press (1) On starting practice. (2) On change of type of practice. (3) On changing address. (4) On temporary absence from duty. (5) On resumption of another practice. (6) On succeeding to another practice. (7) Public declaration of charges • May patent the items, methods & procedures • But it shall be unethical if benefits are not made available in interest of society • A physician shall not give, or receive, any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any patient for medical, surgical or other treatment Should not prescribe or dispense secret remedial agents of which he does not know (composition, manufacture, use, etc. Should not assist nor be a party to either infliction of mental or physical trauma or concealment of torture by other person • Practicing euthanasia shall constitute unethical conduct. • However on specific occasion, the question of withdrawing supporting devices to sustain cardio-pulmonary function even after brain death, shall be decided only by a team of doctors and not merely by the treating physician alone
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  Misconduct  Violation ofregulations  Adultery or improper conduct  Conviction in court of law  Sex determination test  Signing false professional certificates, reports & other documents Any registered practitioner who is shown to have signed or given under his name and authority any certificate, notification, report or document which is untrue, misleading or improper, is liable to have his name deleted from the Register
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  Punishment & Disciplinary Action The punishment given by the appropriate medical council or MCI includes:  Warning  Reprimand – official action  Cancellation of registration  Temporary – for specific period of time.  Permanent
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  Dr.Shirish Kumthekar. SurgeonOncologist. Kumthekar Multispecialty Hospital Jule Solapur Solapur.
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  What is evidence-based medicine? “Evidence-basedmedicine is the integration of best research evidence with clinical expertise and patient values” - David Sackett  “Explicit, judicious, and conscientious use of current best evidence from medical care research to make decisions about the medical care of individuals” 7 July 2018 17Evidence Based Medicine
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  Definition  Conscientious, explicit,judicious use of current best evidence in making decisions about care of an individual patient  Involves integrating individual clinical experience with best external evidence from systematic research
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  Types of EBM Evidence based guidelines- production of guidelines, policy and regulations to be used at the organizational or institutional level  Evidence based individual decision making- use of available evidence to provide best treatment to an individual patient, by an individual physician
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  EBM - Whatis it? Clinical Expertise Research Evidence Patient Preferences Evidence Based Medicine
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  I - Individualclinical expertise  Skills  Judgement  which individual health care workers acquire through  clinical experience and clinical practice Evidence Based Medicine 217 July 2018
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  II - Bestavailable clinical evidence  Clinically relevant research derived from:  basic medical sciences and  patient-centered clinical research into the safety and efficacy of therapeutic interventions.  Systematic Reviews Evidence Based Medicine 227 July 2018
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  Why is EBMimportant?  New types of evidence are being generated which can create changes in the way patients are treated  Although evidence is needed on a daily basis, usually physicians don’t get it. How much is actually being applied to patient care? lack of time out-of-date textbooks the disorganization of the up-to-date journals 7 July 2018 23Evidence Based Medicine
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  Importance of EBMfor practicing clinicians? TIME AVAILABLE TO READ: Less than 1 Hour per Week TIME NEEDED TO KEEP CURRENT ON GENERAL MEDICINE: 19 Articles per DAY 365 Days per Year Source: Davidoff F, Haynes B, Sackett D, Smith R. BMJ. 1995;310:1085-1086. 24Evidence Based Medicine
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  Pre EBM: Passivediffusion (“publish it and they will come”) Early EBM: Pull diffusion (“teach them to read it and they will come”) Current EBM: Push diffusion (“read it for them and send it to them”) Future EBM: Prompt diffusion (“read it for them, connect it to their individual patients”) 7 July 2018 25Evidence Based Medicine
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  For I oncesaved one group by it, while I intentionally neglected another group. By doing that, I wished to reach a conclusion . Al-Rhazi 900 AD 1780 1840 1937/48 1967 1970’s Alvan Feinstein publishes his book Clinical Judgement James Lind publishes review & clinical trial in Treatise on Scurvy Pierre Louis Develops his “numerical method” and changes blood letting practice in France Bradford-Hill publishes Principles of Medical Statistics & MRC trial of streptomycin Some milestones in the history of EBM 7 July 2018 26Evidence Based Medicine
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  Why the suddeninterest in EBM?  Increasing realization among clinicians that years of experience unaccompanied by updating of knowledge can result in decline of clinical performance  The need for valid information about diagnosis, therapy, prognosis, and prevention in this era of consumer activism 7 July 2018 27Evidence Based Medicine
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   The commonman has access to the very same medical literature as the clinicians through numerous sources  Limited time available to the clinician for acquiring information is a major impediment for updating the knowledge from traditional sources 7 July 2018 28Evidence Based Medicine
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  Assumptions of evidence-basedpractices  Not all evidence is equivalent  There is a hierarchy of study design  External evidence can inform but can never replace individual clinical expertise (Sackett et al., 1996)  Starting from the best external evidence and work from there.  Values always influence decisions 7 July 2018 29Evidence Based Medicine
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  Where do wego for help with decisions when we are not sure how to proceed? 7 July 2018 Evidence Based Medicine
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  Decision making inclinical practice using evidence Decision-making is the cognitive process resulting in the selection of a course of action among several alternative possibilities 7 July 2018 Evidence Based Medicine
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  7 July 201832Evidence Based Medicine
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  So in clinicalpractice Disease Treatment options 7 July 2018 33Evidence Based Medicine
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  Ectopic pregnancy Medical Laparoscopic laparotomy 7 July 201834Evidence Based Medicine
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  Outcome – theonly thing that matters 7 July 2018 35Evidence Based Medicine
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  What EBM additionallyprovides is Opportunity for change Opportunity for better treatment 7 July 2018 36Evidence Based Medicine
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  How evidence affectsclinicians •Happy !!! •I am the best !!! •Will the patient recover or not?? •Will they sue me?? •What about my reputation ?? 7 July 2018 37Evidence Based Medicine
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  7 July 201838Evidence Based Medicine
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  Think 100 timesbefore refuting an old time tested method of treatment  Classic example is vaginal hysterectomy for benign diseases  “Give me 2 retractors, 2 scissors , 2 clamps, one tissue holding forceps and one needle holder, I will do a vaginal hysterectomy in any setup” Surgeon 7 July 2018 39Evidence Based Medicine
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  Changes in clinicalpractice shouldn’t be like this 7 July 2018 40Evidence Based Medicine
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  Changes should belike this 7 July 2018 41Evidence Based Medicine
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  The Five-Step Approachto Practicing EBM  Step 1- Framing a Proper, Pertinent, Focused and Answerable Question  Step 2 - Searching the Literature  Step 3 - Critical Appraisal of the Literature  Step 4 –Integrating the Evidence with Clinical Expertise and Patient Values  Step 5 – Evaluating the Process7 July 2018 42Evidence Based Medicine
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  What are thebenefits of adopting EBM?  Minimize the errors in patient care  Reduces the cost of treatment to the patient  Optimizes the quality of patient care  Skills learnt in practicing EBM are the very same ones needed for being a lifelong, self-directed learner  Habit of accessing literature on a daily basis is the best guarantor of ensuring advancement of knowledge and keeping abreast of scientific progress 7 July 2018 43Evidence Based Medicine
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  Who benefits?  Practitionerscurrent knowledge to assist with decision making  Researchers reduced duplication identify research gaps  Community recipients of evidence-based interventions  Funders identify research gaps/priorities  Policy maker current knowledge to assist with policy formulation 7 July 2018 44Evidence Based Medicine
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  Conclusion  Medicine isnot an exact science, but a science of probability  The challenge to physicians is to provide up to- date medical care  The ultimate goal for clinicians should be to help patients live long, functional, satisfying, and pain and symptom free life  By adopting the principles of Evidence Based Medicine, it will be possible to maximize the benefits of scientific research for patient care 7 July 2018 Evidence Based Medicine 45
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   Medical educatorsand medical colleges have the singular responsibility of indoctrinating the principles of EBM as a concept, a philosophy, a religion necessary for being efficient, compassionate, caring, and responsible clinician among the future physicians during their formative years of training 7 July 2018 Evidence Based Medicine 46
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  Society does notconsider us as “Gods” any more...........!  Medical practice.....  In Good old days = Ethical Profession.  In the 20 the century = Profession.  Now in the 21st Century = Professional Business.  This profession was looked upon as the Noblest Profession.  If not God we were treated at least as Demigods.  Now the society looks at us with Suspicion,Jealosey, & we have almost become Villains.
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  Why this situation...... Increasing Consumer awareness......  Knowledgeable patients and relatives.  Increasing presence of Insurance in Medical Practice.  Increasing “shopping attitude” on the part of the patients.  Increasing social intolerance towards “Doctors” as a Community.  Availability of ample “Free Advice”.  Unethical & un professional behaviour.
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  A wake upcall for all of us.....  The Government is trying actively to encroach on our freedom & ease of doing the profession.  We need to correct our professional & social attitude.  We need to actively promote the Good side of our Profession.  We need to enforce on us “self imposed” regulations.  We need to unite, stay united & fight united.  We need to constantly remember that “we are an important part of the society” constantly under the microscope of the public eye.
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  Thank You.........