Meshing together personal and population approaches – reaching the impossible dream

Meshing together personal and population approaches – reaching the impossible dream
Here’s a conundrum. I don’t know the answer. I don’t actually think there is an answer, certainly not a neat pithy one.
Personalisation and person centred is the future. No questions there.
However, there is also great gain that can be had from systematic application of a population level improvement paradigm – by which I mean systematic application of QI techniques and improvement science to high value care processes – ie the application of a range of “targets” we KNOW have good evidence to underpin them.
Unthinking application of “population medicine” can lead to over diagnosis and over treatment, maybe harm and certainly sub optimal use of resource (read: waste) from which others are harmed by rote of opportunity cost.
These two important concepts of person centred vs population approach often come into conflict – for obvious reasons. “Population medicine” is a term thrown around without much thought, making it susceptible to doubt, and even parody.
I’ve been grappling with it with some local GPs for a while now and we don’t have a satisfactory answer. I also asked the ever spectacular RCGP over diagnosis group, who had many useful insights. 
What follows is my hamfisted effort at summarising where I think I’m at in my head. 

1. Evidence and patient preference conflicts.

Invariably the starting point is about the conflicts between evidence based medicine approach and personalisation. This is receiving lots of press of late, and it’s a component of my initial question.
There are ways to mesh these things together in satisfactory way, but it’s not easy. 
Perhaps the conflicts between personalisation and population approach are intrinsic and inevitable, perhaps they are not. Either way they have to be negotiated, actively, in the particular context of each individual patient. 
Many suggest they don’t think “population” and “personal” are always in opposition, although conceptually they do seem to be antithetical. A population of similitudes helps make better personal decisions, particularly in fine tuning drug therapy, and discovering the non-responders. 
Some have suggested the concept of bifocal vision, and different goggles worn in different circumstances and at different times. The concept of “bifocal vision” is interesting and is based on both the population-based evidence and the values and preferences of the individual. Xu writes about this in an excellent article on reconciling patient autonomy and quality improvement through shared decision making. Xu Y, et al. Acad Med. 2016.

2. Some solutions to these conflicts?

Margaret McCartney and others identify the need for both new models of evidence synthesis and shared decision making.

This will help avoid the well cited problems with applying population based evidence to individuals (see box 1) and with luck enable the scaling up of shared decision making, something that there’s even a Cochrane Review that tells us is a winner (yet it’s largely ignored in our search for shiny new toys and magic bullets)
The response of the chair of NICE sums it up stressing both the importance of evidence and the importance of well trained brains to contextualise the evidence
As Iona Heath has said- There are no easy answers, and will never be, but we somehow cannot stop ourselves looking for them – even at the expense of waste and harm.

There are some great resources exist to help. For example the NICE Multimorbidty guidelines and the NHS Scotland Polypharmacy guidelines.

Go use them

3. Going beyond just the evidence, but the application of improvement science to ensuring better uptake of evidence based questions. 
This comes back to my original conundrum – Which was about …….the issue of once we have decided what is .evidence based” can we square the issue of application of improvement science methods to increase coverage of effective things whilst still respecting the personalisation agenda.
For me, the last word on the matter goes to Martin Marshall; a leading thinker in this area from a methodological perspective and from the fact that as a practicing GP in a deprived part of London he sees it at the sharp end. His webinar is excellent and well worth a look. 
Marshall, M. (2015). How relevant is improvement science to general practice? [online].  
In this he cites many examples of application of QI approaches to complex and less complex areas of general practice 

Domestic violence -


CVD prevention –
This gives us a view that it can be done. The seminar links personalised care with QI / population based medicine
The key message is that practicing general practice is complex and requires many trade offs and a lot of judgement. Population approaches are relatively straightforward (If spectacularly under implemented) in scenarios where there are right answer v wrong answer issues. 
However as any GP will tell you, 60% of the patients seen in general practice don’t fit the guidelines, thus taking us back to judgements and trade offs. But as the examples cited by Marshall, some of which are complex the population approach can yield great gain, but shouldn’t replace personalised care. Both can and should co-exist.
As ever, only my thoughts. I don’t know the definitive answer. There may not BE a definitive answer. Be interested in your views.
Thanks to Iona Heath, Caroline Morris, Martin Wilson, Campbell Murdoch, Saurabh Jha – some of whose words are nicked for this directly. 



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