"Realistic medicine" replaces "Evidence-based medicine"?

[Toutafait]

In the Redvers Tribunal case it's being claimed that "evidence-based medicine" is "just an opinion", and not one worthy of respect.

Looking at Scotland, it appears that it's moved away from evidence-based medicine, in favour of what it calls "realistic medicine."

"Realistic Medicine puts the person receiving health and social care at the centre of decisions made about their care. It encourages health and care workers to find out what matters most to patients so that the care fits their needs and situation. It recognises that a one size fits all approach to health and social care is not the most effective path for the patient or the NHS."

Find out more about Realistic Medicine | Right Decisions

"Realistic Medicine encourages shared decision making conversations about your care. It’s also about moving away from a “doctor knows best” culture. This means your doctor or health and care professional should understand what matters to you personally and what your goals are."

Realistic Medicine | NHS inform

On the basis of a skim through a few relevant webpages, it doesn't look like it is intended to displace evidence-based medicine. It is just a (typically bureaucratic and jargony) set of tools to assist with the already-established value of ensuring that patients are properly informed and consulted.

However, it does seem that it has been developed partly to avoid 'waste' in healthcare - one page I looked at emphasises that when patients are well informed and able to express preferences they are more likely to choose less intensive treatment approaches.

Clearly docs do have to consider how to manage the whole business of information, choice and consent, even within an evidence based approach.

The currentRedvers case has just made us a bit oversensitive about possible derogation from EBM

They are right but not for the reasons that they think they are.

They are right because the NHS persists in treating symptoms not causes.

They are right because the NHS is limited with drugs to prescribing only drugs that are listed to be prescribed, and also only for that specific illness.

They are right because those drugs have laid down dose rates that aren't correct for every patient or necessarily correct for every day.

And they are right because a person who feels they are getting better treatment and are more in control of their treatment will often respond as though they are getting better treatment and vice versa.

I took part in the consultation on this document re trans healthcare. I'm surprised to see that they have in fact changed the section which originally said that "All people should be respected as experts in their own care." It's been changed to "A person’s gender identity is a personal experience, and people are experts in their own experiences and needs."

Standards-Gender-Identity-Consultation-Feedback-September-2024.pdf

This is great.

As a chronic alcoholic, getting booze easily matters very much to me and I am delighted that I now get Brandy on prescription

Evidence-based medicine: a term to describe how we can decide what is the best treatment option for patients based on evidence.

Realistic medicine: a term to describe how we can best ignore EBM to justify giving patients the treatment they want.

Just call it what it is: consumerism.

I’ve spoken on here before about the difficulties of having elderly, frail, relatives who seem to get a multitude of appointments to “keep an eye” on conditions.

I do think it makes sense to have a cohesive overview for a patient rather than trundling along the NHS treadmilll. It does depend how it’s used in practice though.

Obviously evidence based medicine should be the backbone but just because you can treat/ test/ scan doesnt mesn you should if there isn’t going to be a benefit to the patient.

I did a web search on “realistic medicine” and it looks ok. I found a paper from 2019 explaining the idea:

https://www.sciencedirect.com/science/article/abs/pii/S0738399119302575

Right from the start it explicitly requires evidence based medicine. It seems to be genuinely about getting more effective medicine by having diagnosis and treatment come from shared understanding between doctor and patient.

I was suspicious too.

I've encountered doctors like this before. "What would you like us to do for you?" "Would you like a CAT scan?" I don't know, do I? Do I need one?

I didn't spend 10+ years at medical school. The way this works is that you, the doctor, tell me, the patient, what to do and which medicine to take, and I follow your instructions and hopefully get better.

My impression is that realistic medicine is about saving money - reducing investigations & treatment of frail elderly people. That may be a cynical take on it. It definitely is not replacing evidence based medicine, which is a different entity (with a clear definition, unlike realistic medicine which is mired in jargon and hard to understand the meaning of).

@EricTheHalfASleeve I agree, if realistic medicine is looking at what the symptoms are on paper, having the medical knowledge (evidence based) of how to treat those symptoms, and then explaining and asking the patient how they want to proceed, and then understanding when they don’t want to. There’s a lot of repeat prescriptions going straight in the bin because the conversation is never had, and older people having invasive treatments up until the end when they just want to be left in peace.

It’s not doing whatever the patient wants regardless of evidence and knowledge. That would be click and collect medicine.

100% agree with this. The concept of realistic medicine is probably not a bad thing but the NHS will find a way to make it overly bureaucratic and fuck it up.

I understand people's concerns and the worry that it is just making medicine more consumerist but I take it to be more about working with the patient about what will really work in their situation. That won't actually happen though, because the NHS doesn't allow the time required and they don't properly train their staff to work in that way. So instead it probably will just be used as an excuse for poor quality care, 'Oh, well, the patient didn't want it' so I didn't bother.

In Scotland, (to be fair, it is part of a wider movement) once a year they have a special day called 'What Matters To You Day' to remind health professionals that their patients are human beings with thoughts and feelings and they need to treat them as such. A) Only one day?! B) Why do they even need a day, this should be absolutely basic. It tells you everything you need to know about the culture in the NHS.

I dont see the two things are necessarily mutually exclusive? HCPs can listen to patients while also offering EBM

I had the completely opposite reaction - I thought of all the followers of 'Dr Google' who are far from realistic!

I know of several people who trawl the internet about symptoms, decide they have them, and then expect their GP to send them for all kinds of expensive investigations, although the GP can tell them straight off that they don't have some or all of the arcane conditions they think they have.

I think I'm with Mapletree1985 on this - I want doctors to be sensitive to me as an individual with my own preferences and fears and hopes, but I also want them to know more than me about what may or may not be wrong with me.

They have studied medicine. I have not. When I have a pain, I know I have a pain. A doctor is many times more likely than me to know what could be causing that pain, and whether or not it is potentially dangerous, or requires treatment, or will go away of its own accord.
EBM is the way to distinguish between those possibilities.

I think this is a very difficult balance.

There is an inescapable tension between EBM approach, which is strictly to treat the symptoms presented, and a more holistic approach which may consider and test out possible causes or alternatives behind the symptoms.

EBM applied in a pure form would treat broken bones in 80 year old woman with painkillers, but never test for osteoporosis. A more holistic view may look at bone density, and may also consider whether walking aids might prevent further falls. Thats not 'evidence based' in a strict sense but its sensible.

I may not be explaining this very well....

It sounds like a development of the shared care model of decision making (https://www.nice.org.uk/what-nice-does/our-guidance/about-nice-guidelines/about-shared-decision-making).

They're different parts of the process of treatment. EBM tells you what works and what doesn't. Shared decision making is to choose between the various 'what works' options, according to the patient's preferences and priorities. Often there's a trade off between speed/effectiveness and adverse effects, or certain treatments for one condition might make another worse. People will have different preferences in those cases.

I can see both benefits and pitfalls with this. It could certainly benefit some people with long term chronic conditions, for instance when I start getting low thyroid symptoms but because my bloods are nudging into the bottom quarter of ‘within acceptable range’ they won’t up the dose a bit, and I end up doing it myself on the sly instead. On the other hand those with a new and serious diagnosis arent going to have the first clue as to what’s best for them, and experience doesn’t fill me with confidence that they deliver the information they need to make a decision in a useful or timely fashion. It also shouldn’t mean that costly procedures can be demanded as a wish fulfilment exercise just because someone is considered an expert in their own ‘lived experience’.

How do people think that someone with gender dysphoria should be treated by doctors? If they want to be castrated, should the doctor explain the risks (eg lifelong incontinence) and then go ahead, and what degree of urgency/priority should an operation that is based on the mental state of the patient be given?
And what about a patient who doesn't actually have gender dysphoria (their sexed body doesn't distress them), but would like to look more like the opposite sex for other reasons?
To what extent is the patient actually the expert in what they "need"? Can the doctor override that on the basis that an operation (or hormones) is not medically necessary or justified? Including on the basis of cost and the higher needs of other patients?
What do you say to a patient who wants to be castrated, when you, the doctor, know that that will lead to lifelong problems (which as well as affecting the patient will cost the NHS a lot of time and money)? Do you just accept the informed consent of the patient?

There's a lot online about adults being able to do what they want with their own bodies. But I think a lot of that comes from the US, where patients are self-financing (via insurance). How much say should an individual have when the NHS is footing the bill, both for the original treatment and then for the life of the patient, as they continue to need medical treatment, often because "sex change" operations cause ongoing problems.

The impression I get from the Scottish policies is that the trans person says what they want, the doctor maybe mentions the risks, and the patient then makes the decision.

There's a transman online who regrets her full transition. She mentions that since having "bottom surgery" she's had to have 13 further operations, and on top of all that she is now having to have all her teeth taken out. It's unending, and in the UK all of that would potentially be done on the NHS, at a time when it's in a state of collapse.

This is absolutely deranged, and downright dangerous!