- Joined
- Sep 15, 2001
- Messages
- 262
- Reaction score
- 2
Hey all. Let me first start with the necessary qualifiers:
1. I respect the wisdom of experience
2. Evidence based medicine has made major contributions towards redefining the current standard of care
3. Reviewing literature and quoting statistics does make you sound cool
That said, I think journal clubs have the potential to drive you insane. It is my non-randomized, entirely retrospective, and anectodal opinion that EBM correlates with schizophrenia. I'm fortunate to be at a program that values cutting edge research and places a high priority on interpretation of the literature. However, the sheer magnitude of information combined with several hundred different perspectives makes it difficult to achieve consensus on anything. As I've rapidly transitioned to actually making decisions (paramedic level decisions don't count because they're formuated on pre-existing protocol), I find frustration increasingly difficult to avoid. It seems that whatever the topic, there's data both supporting and contradicting the current and accepted standard of care.
To sidestep any BNP discussions for a moment, consider the risk-stratification of chest pain. There exists an imperative for ER docs to not only RULE out MIs but predict the occurence of adverse events within 30 days. Clearly, it makes little sense to discharge people if they're at risk of dropping dead in the next two weeks. Through troponins work well as markers of cardiac injury, they aren't good ischemic markers. Furthermore, newer research on cardiac catheterizations suggests that plaques can be both luminal and eccentric (involving the vessel wall). One study cited by our program director showed a "clean" coronary catheterization in someone with impressive main vessel disease as determined by intravascular ultrasound. Despite advances in biomarkers and chemistry, we still miss something like 2% of all MIs. Though a sizeable body of literature about cardiac injury exists, there is still much disagreement on the ideal, "rule out" protocol. Do we stress? Do we perform serial enzymes at Q3 or Q6 ? What about CT angio?
Consider that recent technology advances threaten to undermine our ability to interpret results! Our radiology dept recently took possession of 42 slice CT scanners. Now, everyone has radiological evidence of PE. What is clinically acceptable ? What millimeter of occlusion is considered clinically insignificant? These questions stem, I understand, from CTs obtained on YOUNG and generally HEALTHY trauma victims.
Just mention the word nesiritide to any emergency provider and cardiologist, and you'll get enough opinion to make your head spin. One article says, "Nesiritide is just as safe as nitroglycerin...." The same article, predictably, fails to mention that "safe" only refers to side effects experienced during treatment. Furthermore, there is no mention made of mortality data showing a statistically insignificant trend towards INCREASED mortality in patients recieving the aforementioned infusion. Glance at yet another masterful piece of work and read,"Nesiritide is safe and effective for use in the treatment of cardiogenic pulmonary edema." Then jump on over to MD consult and learn that the prestigious Eugene Braunward himself (of Harrison's Internal Medicine Fame) has just cautioned clinicians to limit BNP's therapeutic use to the very very ill. Just suffering from cardiogenic pulmonary edema only qualifies you as, 'moderately sick' I guess..
How do the more senior residents feel about this obsession with EBM? Since research is constantly in progress, how is it possible to keep up with recent advances ? How do you cope with the apparent contradictions in recommendations from respected expert panels? People are quick to rail against textbooks, but at least the information contained within them is usually more tried, tested, and consistent! I'm glad that our current generation of EPs will be well versed in literature review, but I find it increasingly difficult to formulate cogent therapeutic opinions in the midst of such variation. All too often, it seems that we current and future EPs are forced to make life changing decisions when faced with inadequate infromation, nonsensical histories, non compliant patients, and the threat of litigations. The trend towards EBM, in some cases, simply clouds the picture even further...
Not to mention that our specialty has something like the first or second highest payout rate of malpractice cases that are settled.
😡
1. I respect the wisdom of experience
2. Evidence based medicine has made major contributions towards redefining the current standard of care
3. Reviewing literature and quoting statistics does make you sound cool
That said, I think journal clubs have the potential to drive you insane. It is my non-randomized, entirely retrospective, and anectodal opinion that EBM correlates with schizophrenia. I'm fortunate to be at a program that values cutting edge research and places a high priority on interpretation of the literature. However, the sheer magnitude of information combined with several hundred different perspectives makes it difficult to achieve consensus on anything. As I've rapidly transitioned to actually making decisions (paramedic level decisions don't count because they're formuated on pre-existing protocol), I find frustration increasingly difficult to avoid. It seems that whatever the topic, there's data both supporting and contradicting the current and accepted standard of care.
To sidestep any BNP discussions for a moment, consider the risk-stratification of chest pain. There exists an imperative for ER docs to not only RULE out MIs but predict the occurence of adverse events within 30 days. Clearly, it makes little sense to discharge people if they're at risk of dropping dead in the next two weeks. Through troponins work well as markers of cardiac injury, they aren't good ischemic markers. Furthermore, newer research on cardiac catheterizations suggests that plaques can be both luminal and eccentric (involving the vessel wall). One study cited by our program director showed a "clean" coronary catheterization in someone with impressive main vessel disease as determined by intravascular ultrasound. Despite advances in biomarkers and chemistry, we still miss something like 2% of all MIs. Though a sizeable body of literature about cardiac injury exists, there is still much disagreement on the ideal, "rule out" protocol. Do we stress? Do we perform serial enzymes at Q3 or Q6 ? What about CT angio?
Consider that recent technology advances threaten to undermine our ability to interpret results! Our radiology dept recently took possession of 42 slice CT scanners. Now, everyone has radiological evidence of PE. What is clinically acceptable ? What millimeter of occlusion is considered clinically insignificant? These questions stem, I understand, from CTs obtained on YOUNG and generally HEALTHY trauma victims.
Just mention the word nesiritide to any emergency provider and cardiologist, and you'll get enough opinion to make your head spin. One article says, "Nesiritide is just as safe as nitroglycerin...." The same article, predictably, fails to mention that "safe" only refers to side effects experienced during treatment. Furthermore, there is no mention made of mortality data showing a statistically insignificant trend towards INCREASED mortality in patients recieving the aforementioned infusion. Glance at yet another masterful piece of work and read,"Nesiritide is safe and effective for use in the treatment of cardiogenic pulmonary edema." Then jump on over to MD consult and learn that the prestigious Eugene Braunward himself (of Harrison's Internal Medicine Fame) has just cautioned clinicians to limit BNP's therapeutic use to the very very ill. Just suffering from cardiogenic pulmonary edema only qualifies you as, 'moderately sick' I guess..
How do the more senior residents feel about this obsession with EBM? Since research is constantly in progress, how is it possible to keep up with recent advances ? How do you cope with the apparent contradictions in recommendations from respected expert panels? People are quick to rail against textbooks, but at least the information contained within them is usually more tried, tested, and consistent! I'm glad that our current generation of EPs will be well versed in literature review, but I find it increasingly difficult to formulate cogent therapeutic opinions in the midst of such variation. All too often, it seems that we current and future EPs are forced to make life changing decisions when faced with inadequate infromation, nonsensical histories, non compliant patients, and the threat of litigations. The trend towards EBM, in some cases, simply clouds the picture even further...
Not to mention that our specialty has something like the first or second highest payout rate of malpractice cases that are settled.
😡
