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‘Shared wisdom’ can help achieve patient-centered outcomes
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William Wood
As a stem cell transplantation physician, I come across clinical scenarios all the time in which the “correct” course of action isn’t immediately clear.
These dilemmas occur across the entire transplant continuum. For example, prior to transplantation: What is the prognosis of an unusual presentation of a common disease, and how is this prognosis modified by transplantation? The answer to this question profoundly affects the risk–benefit calculation for transplant, and it may mean the difference between moving forward or not.
If the decision is made to move forward, which conditioning regimen is best, and with what intensity? In many cases, the answer to this question is fairly straightforward, but in others it isn’t. How about for a patient in his early 50s with minimal comorbid illness? How about moderate or severe comorbid illness, and how is “moderate” or “severe” defined?
After transplant, several vexing questions related to prevention or treatment of specific complications inevitably occur. What are the best pharmacologic prophylactic strategies against graft-versus-host disease (GVHD) or infection? How is primary immunosuppression managed, tapered and discontinued?
For diagnosed acute GVHD, what is the best treatment approach when first-line corticosteroids fail to achieve sufficient benefit? How are severe or unusual infections optimally treated? How are the myriad manifestations of chronic GVHD accurately diagnosed and treated in the short and long run? What are the best strategies for preventing or treating relapsed disease? Under which particular circumstances — and using which techniques — do second transplants make any sense?
No clear answers
These questions are difficult because a clear right answer doesn’t always exist. Multiple prior studies have documented significant practice variation from one clinician or center to another in most or all of the areas mentioned above.
Does this mean that if no consensus exists, anything goes? That if the latest published article seems to provide some support for one’s viewpoint — regardless of one’s own expertise in the specific issue — that is good enough?
We are practicing in an era with at least two major clinical imperatives when making decisions like this.
The first is that our patients count on us to provide care recommendations consistent with the state of the science. The science may be messy, variation may exist and expertise in specific areas may be concentrated in geographically scattered locations. Sometimes true local expertise in a given area is not present, despite the overall excellence of the treating location. In my opinion, this is not a reason for failing to seek out the expertise where it does exist.
The second major imperative, I believe, is that our patients want their values and preferences to be integrated into clinical decision making. When we are practicing in areas of uncertainty, however, it is hard to effectively elicit and integrate the voices of our patients into the decisions we make. It is difficult to add a layer of preference sensitivity to our decisions when we have a hard time, in the first place, accurately discerning and weighing the probabilities of hard clinical outcomes such as survival or disability.
These issues are not unique to stem cell transplantation. Many areas of malignant hematology are fraught with similarly challenging clinical dilemmas. Our solid tumor colleagues also encounter diagnostic or therapeutic challenges. The stakes in oncology — literally life and death — are high.
Vision of shared wisdom
How can we move forward? For some, the answer to this has been to learn to trust one’s instincts. As health care providers, we’re highly trained and exposed to recent research on a virtually continual basis. Even if we haven’t encountered a particular situation before, the only way to learn and to develop expertise is to gain experience, and one has to start somewhere. I think this is the “do your best” approach.
I think our patients deserve better than this. We have electronic resources that enable a rapidity of communication that was not possible in earlier years. We need to take advantage of this technology to communicate with our colleagues from other institutions and practice environments more effectively, and almost at the point of care, so that we learn from each other and with each other on an ongoing basis.
Expertise does not need to grow simultaneously and organically in many places at once. We can find ways — through virtual case sharing, online discussions, group wikis and other techniques — to ensure our expertise grows collectively, so the “state of the science” is truly shared among us, in real time and for clinical use.
How can we achieve this utopia? There are several groups that are interested in developing technologies in this space. I’m not sure right now which particular platform will win out and become most readily adopted. In the end, that doesn’t matter much to me. What’s more important, I think, is that as a provider community we begin to acknowledge our personal limitations and subscribe to this vision of shared wisdom. In this way we can move a step closer to consistent achievement of the best patient-centered outcomes possible.
I’d be happy to discuss this further with anyone who has ideas about how to make this vision a reality. I have some ideas myself and would love to collaborate.
For more information:
William Wood, MD, is an assistant professor of medicine in the division of hematology/oncology at the University of North Carolina in Chapel Hill. He also is a HemOnc Today Editorial Board member. He can be reached at UNC Health Care System, Division of Hematology and Oncology, 101 Manning Drive, Chapel Hill, NC 27514; email: william_wood@med.unc.edu. You also may follow him on Twitter (@WoodBD).
Disclosure: Wood is a medical consultant for Best Doctors.