Well, the idea seems to be that character and other intangible attributes of applicants are important and not just academic performance according to this NEJM piece. It's true, of course, although it's nothing new. It's what admissions committees have been after for decades and has long been the focus of applicant interviews and letters of recommendation. But in the minds of some these matters are getting more attention which is refreshing given our rising obsession with measurement in medical education.
In the audio segment accompanying the article the discussant points to a common fallacy in discussions of this topic: the false dichotomy between academic prowess in the sciences and the humanistic qualities desirable in a physician.
Sunday, May 19, 2013
Saturday, May 18, 2013
Thursday, May 16, 2013
Evidence based medicine twenty years later
A few months ago marked the twentieth anniversary of the launch of evidence based medicine (EBM). Now seems a good time for a retrospective. After twenty years what does EBM mean? Where has it taken us? What are the distortions and unintended consequences? You might be surprised.
What I intend to do is start with a little of the history of EBM, talk about the essential notion as originally conceived by the founders, and mention a little about the process as applied to clinical practice today. Then I'll deal with some distortions and misconceptions as well as some surprising unintended consequences.
EBM was launched on November 4 1992 with the publication of this paper in JAMA. I don't recall noticing the paper coming out but when discussions of EBM as a new movement became popular I wondered what was so new about it. After all I thought I had always made clinical decisions based on evidence. I recalled so many of the clinical trials I had applied in my practice through the years. Practicing doctors for the most part, I thought, were conscientious in applying this evidence to their clinical decisions.
What I later learned was that it was not the reliance on evidence but the manner in which it was applied that was new. EBM sought to take things to a new level with a more systematic and rigorous approach to the application of research data.
Very soon after the publication of the JAMA paper, however, misconceptions began to fly. These mainly centered around the idea that EBM was “one size fits all” or “cookie cutter” medicine. That distortion persists today. More on that below. But it prompted some of the founders to publish another paper, which I regard as the second founding document, a paper in BMJ titled Evidence based medicine: what it is and what it is and what it isn't. In it we find what is most widely quoted today among aficionados as the essential definition:
Note that EBM is about individual expertise and judgment and about the individual patient. More on that below.
What about the process? It's useful to take a look at that because it can be rather onerous and I suspect that not many of us today practice it in its pure form chiefly because of the time it takes. I covered the process of EBM in a couple of long posts a few years ago. Suffice it to say here that it starts with asking a clinical question focused on your patient and converting it into a set of search terms that can be applied to a search engine such as PubMed. Citations thus retrieved are appraised according to a set of criteria after the model of the EBM pyramid. There are several variations on the basic pyramid theme, an example of which is shown here. Using the criteria the list of citations is trimmed down to those articles that are current and deemed of sufficient quality. The final step involves taking the information thus selected and applying it to the patient's idiosyncrasies including circumstances, preferences and values.
That last piece is often lost in discussions today when EBM is invoked to guide public policy. Herein lies one of the more pervasive distortions of EBM. Public policy discussions about the direction of health care got into high gear early in the Obama administration when the gimmicky phrase “comparative effectiveness research” entered the lexicon and debates raged about health care reform. There were diverse arguments about the direction health care should go but many of them sought to homogenize it, citing such things as the Dartmouth Atlas data and other sources which showed variation in delivery. The idea was that through various forms of central control one could minimize the variation which after all many believed to be the enemy of quality and efficiency. Pathways, performance measures, positive incentives and negative incentives all seek to do this and many proponents try to bolster their arguments by appealing to EBM. They thereby only reflect their ignorance about what EBM is. Maybe you like central control and can make some good arguments for it but you can't invoke EBM to support those arguments. EBM is diametrically opposed to central control. If you've any doubt about whether EBM concerns primarily individual decision makers and individual patients, watch this interview with David Sackett, one of the movement's founders:
I don't purpose to argue against central control here. Maybe it has something to recommend it but by definition the more external forces encroach on your decision making the less you will practice EBM. Just by definition.
But even when EBM is practiced according to its core principles there are unintended consequences. These relate to a fatal flaw of EBM found in that pyramid I referenced earlier. What I am referring to is that though not intended by its founders, application of EBM has led to numerous promotions of quackery. I have cited examples of this many times before as have David Gorski and other bloggers. It has to do with placing scientific plausibility at the bottom of the EBM pyramid, as I once explained:
Kimbal Atwood had a good example of how this has been applied to promote nutty ideas like homeopathy, in which occasional weak clinical trials which appear to favor homeopathy by chance variation trump overwhelming basic science information against it:
The way we got into this fix is that the founders of EBM realized we couldn't rely only on scientific rationale. That has gotten us into trouble in the past. High level outcome based evidence is needed to be placed in the mix to address that problem. But what the EBM apologists left out was the fact that while scientific plausibility couldn't be the sole basis for making clinical decisions it couldn't be ignored. It needed to be a prerequisite.
Solutions? A group of physicians and scientists have recognized that EBM's unintended consequence could be avoided by giving basic scientific plausibility its due place while following the other EBM principles. You can find out lots more about that at their website.
So what do you think about EBM 20 years later? The verdict is mixed but it hasn't lived up to its promise. Maybe with the help of science based medicine (SBM) we'll get there.
What I intend to do is start with a little of the history of EBM, talk about the essential notion as originally conceived by the founders, and mention a little about the process as applied to clinical practice today. Then I'll deal with some distortions and misconceptions as well as some surprising unintended consequences.
EBM was launched on November 4 1992 with the publication of this paper in JAMA. I don't recall noticing the paper coming out but when discussions of EBM as a new movement became popular I wondered what was so new about it. After all I thought I had always made clinical decisions based on evidence. I recalled so many of the clinical trials I had applied in my practice through the years. Practicing doctors for the most part, I thought, were conscientious in applying this evidence to their clinical decisions.
What I later learned was that it was not the reliance on evidence but the manner in which it was applied that was new. EBM sought to take things to a new level with a more systematic and rigorous approach to the application of research data.
Very soon after the publication of the JAMA paper, however, misconceptions began to fly. These mainly centered around the idea that EBM was “one size fits all” or “cookie cutter” medicine. That distortion persists today. More on that below. But it prompted some of the founders to publish another paper, which I regard as the second founding document, a paper in BMJ titled Evidence based medicine: what it is and what it is and what it isn't. In it we find what is most widely quoted today among aficionados as the essential definition:
It's about integrating individual clinical expertise and the best external evidence...
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
Note that EBM is about individual expertise and judgment and about the individual patient. More on that below.
What about the process? It's useful to take a look at that because it can be rather onerous and I suspect that not many of us today practice it in its pure form chiefly because of the time it takes. I covered the process of EBM in a couple of long posts a few years ago. Suffice it to say here that it starts with asking a clinical question focused on your patient and converting it into a set of search terms that can be applied to a search engine such as PubMed. Citations thus retrieved are appraised according to a set of criteria after the model of the EBM pyramid. There are several variations on the basic pyramid theme, an example of which is shown here. Using the criteria the list of citations is trimmed down to those articles that are current and deemed of sufficient quality. The final step involves taking the information thus selected and applying it to the patient's idiosyncrasies including circumstances, preferences and values.
That last piece is often lost in discussions today when EBM is invoked to guide public policy. Herein lies one of the more pervasive distortions of EBM. Public policy discussions about the direction of health care got into high gear early in the Obama administration when the gimmicky phrase “comparative effectiveness research” entered the lexicon and debates raged about health care reform. There were diverse arguments about the direction health care should go but many of them sought to homogenize it, citing such things as the Dartmouth Atlas data and other sources which showed variation in delivery. The idea was that through various forms of central control one could minimize the variation which after all many believed to be the enemy of quality and efficiency. Pathways, performance measures, positive incentives and negative incentives all seek to do this and many proponents try to bolster their arguments by appealing to EBM. They thereby only reflect their ignorance about what EBM is. Maybe you like central control and can make some good arguments for it but you can't invoke EBM to support those arguments. EBM is diametrically opposed to central control. If you've any doubt about whether EBM concerns primarily individual decision makers and individual patients, watch this interview with David Sackett, one of the movement's founders:
I don't purpose to argue against central control here. Maybe it has something to recommend it but by definition the more external forces encroach on your decision making the less you will practice EBM. Just by definition.
But even when EBM is practiced according to its core principles there are unintended consequences. These relate to a fatal flaw of EBM found in that pyramid I referenced earlier. What I am referring to is that though not intended by its founders, application of EBM has led to numerous promotions of quackery. I have cited examples of this many times before as have David Gorski and other bloggers. It has to do with placing scientific plausibility at the bottom of the EBM pyramid, as I once explained:
...that this failure of EBM is more than just one of occasional unintended consequences. While it may have been unintended in the minds of the original founders, now it's systematic.
The problem is illustrated by the evidence pyramids, which are at the very core of the teaching about EBM. There are numerous versions of these pyramids, and Gorski links to a few examples, but what they have in common is that they put biologic plausibility (variously termed basic science, physiologic rationale, etc) at the bottom if they include it at all.
A casual observer might think that putting basic scientific rationale at the bottom means it's intended to be foundational (remember the old stepped care diagrams for treatment of hypertension and rheumatoid arthritis?). But that's not the way the EBM hierarchies of evidence are designed. Instead, higher levels on the pyramid trump those below. Students of EBM are taught to start at the top of the pyramid and “drill down,” level-by-level, until they find the evidence they want, and stop there.
Kimbal Atwood had a good example of how this has been applied to promote nutty ideas like homeopathy, in which occasional weak clinical trials which appear to favor homeopathy by chance variation trump overwhelming basic science information against it:
When this sort of evidence is weighed against the equivocal clinical trial literature, it is abundantly clear that homeopathic “remedies” have no specific, biological effects. Yet EBM relegates such evidence to “Level 5”: the lowest in the scheme. How persuasive is the evidence that EBM dismisses? The “infinitesimals” claim alone is the equivalent of a proposal for a perpetual motion machine. The same medical academics who call for more studies of homeopathy would be embarrassed, one hopes, to be found insisting upon “studies” of perpetual motion machines. Basic chemistry is still a prerequisite for medical school, as far as I’m aware.
The way we got into this fix is that the founders of EBM realized we couldn't rely only on scientific rationale. That has gotten us into trouble in the past. High level outcome based evidence is needed to be placed in the mix to address that problem. But what the EBM apologists left out was the fact that while scientific plausibility couldn't be the sole basis for making clinical decisions it couldn't be ignored. It needed to be a prerequisite.
Solutions? A group of physicians and scientists have recognized that EBM's unintended consequence could be avoided by giving basic scientific plausibility its due place while following the other EBM principles. You can find out lots more about that at their website.
So what do you think about EBM 20 years later? The verdict is mixed but it hasn't lived up to its promise. Maybe with the help of science based medicine (SBM) we'll get there.
Antibiotics and the risk of sudden cardiac death
In the May 17 2012 issue of the NEJM Ray et al reported an increased risk of sudden cardiac death attributable to the use of azithromycin. I blogged that issue here. The study was limited, being a cohort study based on administrative data and the absolute risk was low but its findings were compelling, particularly in regard to the timing of SCD in relation to the use of azithromycin. A more recent paper in the Journal failed to uphold the association of cardiac risk with azithromycin. A perspective piece in the same issue addresses the discrepancy between these studies. According to their analysis the findings of Ray et al are real and the discrepancy between the two studies may be attributable to differing patient populations and in the more recent paper a survival advantage attributable to azithromycin in the treatment of pneumonia that may have counterbalanced any adverse cardiac effect. It has long been known, of course, that macrolides as a class prolong the QT interval. Although that problem may not extend equally across the class there is plausibility to a risk of sudden cardiac death attributable to azithromycin.
They also point out findings in the Ray paper suggesting that levofloxacin has similar cardiac risk to azithromycin but not ciprofloxacin. Quinolones have been implicated in QT interval prolongation and Torsades but the risk appears not to extend equally across the class.
So what are we to make of all this? There are several points worth noting:
In the perspective piece the authors point out the FDA's statement regarding azithromycin:
I would submit that those concerns would apply to the use of all macrolides as well as all quinolones with the possible exception of ciprofloxacin. That makes them somewhat impractical to implement but there are precautions that can be taken, in terms of minimizing the other risk factors I note below.
While the absolute risk of antibiotic induced QT prolongation and Torsades is low it is magnified by other risk factors that may interact and conspire to produce a catastrophic event. Hospitalization is a likely setting for the perfect storm that may bring these factors together. Hypomagnesemia and hypokalemia, both of which are powerful risk factors for QT prolongation, are common in hospitalized patients. Administration of proton pump inhibitors as “GI prophylaxis” to patients with pneumonia or other acute respiratory conditions causes hypomagnesemia. Poor oral intake, the common use of diuretics in the hospital and the use of normal saline as the default IV fluid may all produce hypokalemia. The concomitant use of other drugs known to prolong the QT interval (eg haloperidol and ondansetron) is common in hospitalized patients. So just being hospitalized may invite a combination of risk factors.
Recall as I pointed out year before last that patients who die while hospitalized with pneumonia tend to do so suddenly rather than according to any expected trajectory of hypoxia or organ failure. That observation just heightens the concerns mentioned above.
Finally, all that's new about this issue is the hype. The concerns have existed for a long time and over five years ago I cited a paper making the case that close attention to the electrocardiogram was warranted for any patient being treated for infection (or beyond that for most all patients sick enough to be hospitalized).
They also point out findings in the Ray paper suggesting that levofloxacin has similar cardiac risk to azithromycin but not ciprofloxacin. Quinolones have been implicated in QT interval prolongation and Torsades but the risk appears not to extend equally across the class.
So what are we to make of all this? There are several points worth noting:
In the perspective piece the authors point out the FDA's statement regarding azithromycin:
On the basis of its review, the FDA approved revisions to azithromycin product labels regarding risks of QT-interval prolongation and the associated ventricular arrhythmia torsades de pointes. The revised labels advise against using azithromycin in patients with known risk factors such as QT-interval prolongation, hypokalemia, hypomagnesemia, bradycardia, or use of certain antiarrhythmic agents, including class IA (e.g., quinidine and procainamide) and class III (e.g., dofetilide, amiodarone, and sotalol) — drugs that can prolong the QT interval.
I would submit that those concerns would apply to the use of all macrolides as well as all quinolones with the possible exception of ciprofloxacin. That makes them somewhat impractical to implement but there are precautions that can be taken, in terms of minimizing the other risk factors I note below.
While the absolute risk of antibiotic induced QT prolongation and Torsades is low it is magnified by other risk factors that may interact and conspire to produce a catastrophic event. Hospitalization is a likely setting for the perfect storm that may bring these factors together. Hypomagnesemia and hypokalemia, both of which are powerful risk factors for QT prolongation, are common in hospitalized patients. Administration of proton pump inhibitors as “GI prophylaxis” to patients with pneumonia or other acute respiratory conditions causes hypomagnesemia. Poor oral intake, the common use of diuretics in the hospital and the use of normal saline as the default IV fluid may all produce hypokalemia. The concomitant use of other drugs known to prolong the QT interval (eg haloperidol and ondansetron) is common in hospitalized patients. So just being hospitalized may invite a combination of risk factors.
Recall as I pointed out year before last that patients who die while hospitalized with pneumonia tend to do so suddenly rather than according to any expected trajectory of hypoxia or organ failure. That observation just heightens the concerns mentioned above.
Finally, all that's new about this issue is the hype. The concerns have existed for a long time and over five years ago I cited a paper making the case that close attention to the electrocardiogram was warranted for any patient being treated for infection (or beyond that for most all patients sick enough to be hospitalized).
Wednesday, May 15, 2013
Monday, May 13, 2013
Discharge planning information for patients
This is from the JAMA series on information for patients and families and is a nice easy to read summary of what they can expect as they navigate through the transition process.
Sunday, May 12, 2013
Shigatoxin associated hemolytic uremic syndrome (D+ HUS)
As pointed out in this review, the classic form is a pediatric entity. When cases arise in adults they are less typical and the distinction from TTP is blurred. These cases are probably best termed TTP-HUS and should not argue against plasma exchange therapy.
Saturday, May 11, 2013
Annals of Internal Medicine promotes acupuncture for comparative effectiveness research
Often in my professional development I am taught to consider the source. Information presented by pharmaceutical companies is to be rejected. Blogs are to be read with an extra measure of caution. A journal's reputation means something. Not so much anymore. Now we have to evaluate medical claims on their own merits regardless of the source. That demands a little more effort. Why do I say this? A case in point is the trend over the last few years in so called top tier medical journals toward the promotion of quackery. Just recently the Annals of Internal Medicine published this study on acupuncture for treatment of seasonal allergic rhinitis. The paper is cosmetically scientific with all the jargon and trappings of evidence based medicine:
Initially I just glanced casually at the study. This type of thing is not so unusual anymore. It was just another promotion of a nutty idea by a mainstream medical journal under the guise of evidence based medicine. It was so dense with scientific verbiage and so circumspect sounding I knew it would take a little effort to expose it. And at the time I was busy. And tired.
Well, fortunately Mark Crislip over at Science Based Medicine did it for me. When you read his post I suggest you skip down to the middle where he begins the actual analysis of the paper. The real devil is in the details and he unpacks them nicely:
It's all quite ridiculous. One of the more unintentionally funny papers in the medical literature. Or was it intentional? It's hard to know from just reading the paper whether or not it's a parody. But apparently it was intended to be taken seriously because in an accompanying editorial the journal elevates it to the realm of public policy, specifically “comparative effectiveness research.”
This type of nonsense has been going on in high impact medical journals for several years now and it is getting worse. It started out in BMJ about a decade ago and over time has metastasized to other journals. Over at Quackwatch Steve Barrett put BMJ on his black list years ago and subsequently added the Annals.
But the Annals and BMJ have managed to maintain a good reputation, so now a journal's reputation means little. Whether it's indexed in Medline means little. The same can be said of broad categories such as journals and blogs. It's strictly buyer beware. I've said for a long time that relying on the source to evaluate the quality of information is intellectually lazy. Now, as illustrated by the paper and editorial in question, it's flat out unreliable.
There's not much being done to stop the trend but as time and energy permit I'll do what I can to expose it. In the meantime maybe there's a positive here. It means, more than ever before, that we have to evaluate medical information on its own merits rather than considering too strongly the source. Something we should have been doing all along.
Results: Compared with sham acupuncture and with RM, acupuncture was associated with improvement in RQLQ score (sham vs. acupuncture mean difference, 0.5 point [97.5% CI, 0.2 to 0.8 point; P less than 0.001]; RM vs. acupuncture mean difference, 0.7 point [97.5% CI, 0.4 to 1.0 point; P less than 0.001]) and RMS (sham vs. acupuncture mean difference, 1.1 points [97.5% CI, 0.4 to 1.9 points; P less than 0.001]; RM vs. acupuncture mean difference, 1.5 points [97.5% CI, 0.8 to 2.2 points; P less than 0.001]). There were no differences after 16 weeks in the first year. After the 8-week follow-up phase in the second year, small improvements favoring real acupuncture over the sham procedure were noted (RQLQ mean difference, 0.3 point [95% CI, 0.03 to 0.6 point; P = 0.032]; RMS mean difference, 1.0 point [95% CI, 0.2 to 1.9 points; P = 0.018]).
Limitation: The study was not powered to detect rare adverse events, and the RQLQ and RMS values were low at baseline.
Conclusion: Acupuncture led to statistically significant improvements in disease-specific quality of life and antihistamine use measures after 8 weeks of treatment compared with sham acupuncture and with RM alone, but the improvements may not be clinically significant.
Initially I just glanced casually at the study. This type of thing is not so unusual anymore. It was just another promotion of a nutty idea by a mainstream medical journal under the guise of evidence based medicine. It was so dense with scientific verbiage and so circumspect sounding I knew it would take a little effort to expose it. And at the time I was busy. And tired.
Well, fortunately Mark Crislip over at Science Based Medicine did it for me. When you read his post I suggest you skip down to the middle where he begins the actual analysis of the paper. The real devil is in the details and he unpacks them nicely:
The big difference is that acupuncture is a form of magic that is likely to get published in formerly reliable journals complete with positive spin: Acupuncture in Patients With Seasonal Allergic Rhinitis. A Randomized Trial...
A careful and critical reading of the paper gives compelling evidence that acupuncture does nothing, in line with all the other well-designed acupuncture studies. The cognitive disconnect between the editorial and conclusion and the data presented in the paper is a wonder to behold. And most people will read only the spin in the abstract and the editorial, not noticing the fatal flaws, and erroneously conclude that acupuncture has efficacy.
Yet another reason why I am glad I let my Annals subscription lapse years ago.
It's all quite ridiculous. One of the more unintentionally funny papers in the medical literature. Or was it intentional? It's hard to know from just reading the paper whether or not it's a parody. But apparently it was intended to be taken seriously because in an accompanying editorial the journal elevates it to the realm of public policy, specifically “comparative effectiveness research.”
This type of nonsense has been going on in high impact medical journals for several years now and it is getting worse. It started out in BMJ about a decade ago and over time has metastasized to other journals. Over at Quackwatch Steve Barrett put BMJ on his black list years ago and subsequently added the Annals.
But the Annals and BMJ have managed to maintain a good reputation, so now a journal's reputation means little. Whether it's indexed in Medline means little. The same can be said of broad categories such as journals and blogs. It's strictly buyer beware. I've said for a long time that relying on the source to evaluate the quality of information is intellectually lazy. Now, as illustrated by the paper and editorial in question, it's flat out unreliable.
There's not much being done to stop the trend but as time and energy permit I'll do what I can to expose it. In the meantime maybe there's a positive here. It means, more than ever before, that we have to evaluate medical information on its own merits rather than considering too strongly the source. Something we should have been doing all along.
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