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Handling Uncertainty
Standard and local practices in the case of libido and contraception in evidence-based decision-making
Jennifer Sarah Hester-Moore
Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
Abstract
This paper draws from a qualitative study of interviews with 14 health practitioners to explore the use of reproductive health guidelines in contraception consultations. An aim of standardised guidelines is to encourage health practitioners to use scientific evidence in clinical decision-making.
The paper uses health practitioners' management of decreased libido as a case study to highlight the paradox of evidence based medicine when the evidence and guidelines do not match clinical presentations and practice. This case study also illustrates how the tension between guidelines and clients' needs are managed in the clinical encounter.
The paper suggests that an interactionist approach, which emphasises the interrelationship between guidelines and health practitioners' clinical work, is an alternative to standardisation for handling uncertainties in clinical practice.
Keywords
sociology, evidence based medicine, health professionals, contraception, interactionism, decision-making
Article Text
Contraceptive use among Australian women is widespread. A recent quantitative study on the contraceptive practices of a representative sample of Australian women aged 16-59 reported that 70.8% of their respondents were using a method of contraception (Richters et al 2003). Prescribing contraception is also an important aspect of many health practitioners' work. Calabresi (2002) describes contraception prescriptions as the 'bread and butter of general practice'. In some areas of contraception consultations, the FPV health practitioners use guidelines and evidence-based medicine (EBM) strictly. However, in the case of libido, their practices are not standardised.
This article explores accounts that were generated from interviews with health practitioners (ten doctors and four nurses) from Family Planning Victoria (FPV), who use sexual and reproductive health guidelines in contraception consultations. In this study, decreased libido, attributed to hormonal contraception1, is used as a case study to illustrate the difficulties health practitioners encounter when the scientific evidence is limited. The biomedical literature (Anonymous 1984; Bjelica et al 2003; Fraser and Dennerstein 1994; Martin-Loeches et al 2003; Raudrant and Rabe 2003) reports that decreased libido as a result of hormonal contraception is infrequent, occurring in 8% of women. By contrast, the FPV health practitioners indicated that it is a common presentation. On the basis of this discrepancy between evidence and presentation, this paper asks how FPV health practitioners manage medical uncertainty and the requirement to use scientific evidence when the evidence is limited or absent.
...continues...
The health practitioners' accounts illustrate that there can be uncertainty and complexity even when there is abundant and clear evidence. The uncertainties and contingencies are heightened when there is little or no evidence. The disjuncture between the guidelines/evidence and clinical presentations and practice, highlight paradoxes in evidence-based medicine: health practitioners are required to use evidence when there is none. Returning to the question: how do health practitioners manage the requirement to use scientific evidence when the evidence is limited or absent? The health practitioners' accounts illustrate the importance of using strategies to handle uncertainty, rather than applying strict standardisation. Faced with inevitable uncertainties, handling libido requires transformative interactions rather than reversions to sameness and standardisation. This involves negotiating in and between guidelines and clients. The FPV health practitioners interviewed are actively involved in attempting to construct new frameworks that accommodate standard guidelines and demonstrate a fluid approach to difference and uncertainty. Symbolic interactionism could also be useful for, and applied to health professionals other than doctors and nurses, such as physiotherapists, who have to manage uncertainties in clinical practice.
Notes
1 Hormonal contraceptive methods include the oral contraceptive pill, Depo-Provera (injection), implants and vaginal rings. Non-hormonal contraceptives include barrier methods such as diaphragms, cervical caps, sponges and IUDs (although there are also hormonal IUDs such as Mirena).
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