Evidence-based Attire Part 1

I am going to write a 2 part series on what we should wear as physicians. I was inspired to do this when my resident said he has received an email declaring all male physicians must wear ties. I mostly have abandoned tie wearing as they are hot, uncomfortable and I just can’t find matching ties to many of the shirts I want to wear and don’t want to commit a fashion faux pas. I also perceived them to be an infection risk (I will address this in part 2 of this series). When I don’t wear a tie I wear my white coat. When I wear a tie I often forgo the white coat. What do patients think about this?

I felt it important to try to review a smattering of the literature on the topic. I admit I didn’t do a full literature review because the importance of this is just not worth the time. I did randomly select from the studies I did find so as not to only support my biased opinion that patients don’t really care what we wear.

There is a fair amount of literature on this topic in both the medical and dental world. Many of the studies included pictures like the following for patients to critique and give their opinion of the physicians depicted. They were often asked about the professionalism of the attire and their desirability of certain aspects of dress.

I didn’t find a dress option I really had hoped to find information on: white coat but no tie.

What do patient’s think about how we dress?

Below are some selected figures from studies showing these results. This first table shows that wearing a tie was fairly desirable but not as desirable as a name tag and white coat.

This is from a study of anesthesiologists (https://goo.gl/kTKUoM)

The figure below was from a study of anesthesiologist. It included 110 patients. You can see that wearing a tie was felt to be important by about 25-30% of them. Wearing a name tag and white coat was more important.

Another from a study of anesthesiologists (https://goo.gl/5fMh7k)

The figure below suggests that wearing a ties led to greater patient comfort in dealing with the doctor. Interestingly, not wearing a tie has the same ranking as wearing a white coat in patient’s comfort of dealing with a doctor dressed in such a way.

Finally, the table below shows patients in this study mostly disagreed that ties were important and didn’t even feel white coats were all that important. They felt is was most important for doctors to act professionally.

So, there you have it. White coats and name tags seem to be the most important. It helps patients identify us as doctors and we are perceived to be more professional in the white coat. Ties have mixed results. I am still undecided as to how I feel about this. I used to love wearing ties…now not so much. I think I will make my decision after I review the infection risk data. Stay tuned for that installment which will be coming soon.

What do you think?

Rebuttal to Tarnished Gold: The Sickness of Evidence-Based Medicine by Hickey and Roberts

Unfortunately, a lot has been going on in life and I haven’t posted as much as I would like to.   The main reason has been some major life changes and class work (I’m getting a master in educational technology). Another reason has been a lack of inspiration. Well, I am inspired now.

Tarnished Gold book cover image

Recently on a listserv I subscribe to someone mentioned a book called Tarnished Gold: The Sickness of Evidence-based Medicine. Some said it was a great book and many said it was garbage. I had never heard of it but could tell by the comments it is an anti-EBM piece. The EBM paradigm is evolving, as it should. Part of how a paradigm evolves is critical review of its tenants.  This book seems to challenge the tenants of EBM.  It’s important to look at all sides of a story to formulate a complete understanding of it. My bias is for EBM principles. I plan to read this book and give my rebuttal to each chapter. I will be as fair as I can and give them credit for good ideas and challenge ones I don’t agree with.  I have read the preface, foreword, and 1st chapter and know I will have a lot to write about.

Look for my 1st installment tomorrow.

Using a Personal Learning Network for Professional Development

I’ve been absent awhile and its good to be back. I started a new degree program (Master in Educational Technology) and I just haven’t had a lot of extra time to do other things. Why, you might ask, am I getting yet another degree (will be my 4th)? When I developed my online course in EBM for the medical school I became very interested in online teaching which then led to an interest in mobile teaching which then led me to use a variety of tech tools for teaching. I realized I had no real reason to use one tool over another except for its “coolness factor”. I then decided I wanted formal training in educational technology. All this rambling is to set up the fact that I learned about educational technology through my personal learning network. I made the video below explaining what this is and how to develop one using social media. While I focus on education I do list some EBM thought leaders you should follow on Twitter (in addition to me of course!).

Finally Someone Has Some Sense: Patient-Centered Quality Assessment

This week in JAMA Eve Kerr and Rodney Heyward wrote an important opinion piece about patient centered performance measurement. So here’s the problem with our current performance measurement paradigm: one size fits all. Guidelines have been bastardized into performance measures. Administrators/insurers/etc then hold us accountable to the measures. So what’s the problem?

Well guidelines were meant to be just that guidelines, not rules. When they are made into performance measures they become rules. Rigid rules that are applied to very variable patients. Deviation from the rules leads to the clinician being “dinged”. What this often leads to is inappropriate care. Patients have medication regimens inappropriately escalated to reach an arbitrary number. This often leads to harm either directly as an effect of that medication or through medication interactions. Patients get tests they don’t need (for example, colon cancer screening in patients with multiple comorbidities and limited life expectancy).

Quality graph

I have always felt that quality is very personal. What I view as quality will not be the same as someone else. This applies to all aspects of life, not just medicine. I have always felt that we should negotiate with our patients for what constitutes quality care FROM THEIR STANDPOINT. Aren’t they the ones who matter most? Why is it some administrator decides what constitutes quality care?

Let’s look at an example. Suppose I have a patient with diabetes who is on maximal oral therapy but her A1C is 9. It would be recommended to give insulin. What if the patient doesn’t want insulin no matter what. She understands the risk of longterm uncontrolled insulin. Is it poor quality care that I honor her request to only stay on oral therapy? Again from whose perspective should we evaluate quality?

I think we are slowly moving to including the patient in quality assessment. It needs to go further to patients being actively involved in developing their own quality report card. Then we can be measured for how well we meet quality.

Systems Give Us What They Are Designed To Give: Work Hour Restriction Outcomes

A colleague of mine (DB) has a great blog (medrants.com). He posted (http://www.medrants.com/archives/7199) an excellent observation that ABIM pass rates are declining since the work hour restrictions have gone into place. I commented back that why would we expect any different because systems give us exactly what they are supposed to give us. In this case less knowledgeable residents.

The proof is in the scores. Why? My theory is that they waste their off time with being off and not studying. When I was a resident in the mid 90s we had no restrictions, no admission caps and only 1 guaranteed day off a month. We stayed at the hospital until late afternoon at least if not early evening routinely. We studied alot during the day in our down time. The satellite library at the hospital was full of us studying (and yes BSing). I saw alot more patients and did alot more to them than this current generation. Interestingly I dont recall mass killings and mayhem at my training hospitals. But for some reason we have accepted a system (work hour restrictions and admission caps) without testing it ahead of time. No drug gets to market this way but for some reason its ok to let doctors get to market this way.

Doctors are on the clock

Being a doctor is complex. Clinical reasoning relies on matching the patient’s story to an illness script. You build illness scripts from studying books (print or electronic…doesnt matter) and by patient interactions. You have to see lots of patients to enhance and mature your illness scripts. Therein lies the problem…..less studying and less patients. Wow…how did we ever get these lower passing rates. Its hard to understand (sarcasm detected). Oh well it doesnt matter. I am sure the wonderfully designed quality measures will make it all better.

Foiled Again! Study Shows CHF Performance Measures Don’t Help Much

A study published in the American Heart Journal shows what putting the cart before the horse does (http://www.ncbi.nlm.nih.gov/pubmed/22795286?dopt=Abstract). What do I mean? We (the collective we) roll out performance measures without testing them. Like any other intervention we should make sure they work to achieve the desired outcomes- improved “performance”  (notice I didn’t say quality….but that’s a whole topic in and of itself). But as usual someone thinks up a measure and we adopt it just because it might make sense.

The measures that were tested were:

  1. evaluation of LV systolic function
  2. administration of ACE-I or ARBs
  3. provision of smoking cessation counseling, and
  4. provision of discharge instructions

The outcomes they hoped to improve were 30 day mortality and hospital readmission- both worthy goals. The study showed that hospitals did a good job meeting these measures (94% with all 4 measures). Despite this…

“After adjusting for factors including patient demographics, socioeconomic factors, hospital volume, and type of hospital, there were no differences detected in 30-day mortality or readmission rates between hospitals in the top 25% and all others

The authors did find that hospitals located in areas with higher household income and those with a greater volume of HF admissions had decreased mortality rates.”

This is the second study on this same topic which essentially showed the same thing (JAMA. 2007;297:61-70)

“Current heart failure performance measures, aside from prescription of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge, have little relationship to patient mortality and combined mortality/rehospitalization in the first 60 to 90 days after discharge. Additional measures and better methods for identifying and validating heart failure performance measures may be needed to accurately assess and improve care of patients with heart failure”

So why don’t we require measures be tested before we monitor hospitals and physicians for compliance with these measures? Surely we wouldn’t treat a new drug the same way?

Know Thy Limitations

Recently I tried something new for our resident journal club. I am using Edmodo (wwww.edmodo.com) to post the readings and the protocol (boring) and to stimulate learning by posting “Homework Questions” that require learners to digest the background information and relay how they might use it (exciting). One resident had a great insight that many of us dont think about—- the limitations of our tools. She pointed out that a clinical prediction rule she uses (the CHADS2 score for afib) wasnt as good as she thought.

For some reason, as doctors, we assume tests are really good….prediction rules are accurate…..treatments always help. These tools are better than nothing (some of the time) but they arent perfect. This resident pointed that out in an insightful way. Bravo to her. I challenged our journal club group to look at things they use regularly and review their development. Know their limiations.

I see rules used improperly all the time (for example reporting a TIMI score for a patient with nonanginal chest pain) and when I call the resident or student out for using it improperly I usually get a blank stare. They dont realize the tool cant be used in that situation.  They are using tools in ways they werent developed for. Who knows if they work or not in this application.  We as educators, especially as EBM educators, need to challenge ourselves and our learners to get know (how they were developed and validated) the tools we rely on and know their limitations.

And so it begins….

I have been thinking about blogging for some time but never took the plunge. Well I just plunged.

This blog will be devoted to interesting bits about the limitations of evidence, how to use evidence in the care of patients, an occasional summary of the evidence itself, and about teaching EBM.

I am embarking on an interesting journey to develop an online course on evidence based medicine for UAB medical students. I previously taught a standard lecture course on EBM but when the curriculum changed my course became a “theme” and thus was mostly dropped from the curriculum (despite it being a theme of the curriculum– go figure!). “Surprisingly” the students’ step 1 scores on EBM type material plummeted. Who would have thought that if they didn’t learn the material they wouldn’t score well on a test? I recently received a fairly large grant to develop an online course to guide the students in learning how to be an EBM practitioner.

This has been an amazing experience so far. I have learned a lot about teaching and learning (though I have been a medical educator for over a decade I keep realizing I don’t know as much as I thought about teaching), curriculum design, and the future I think (and hope) of medical education. I hope my course can become a demonstration project for UAB so that more courses will develop online components and get away from the silly idea of lecturing at medical students and making them learn at our (the teachers) pace and not their own.