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Man v mountain: how to overcome the evidence overload

By Joseph Ting, University of Queensland

Most doctors shudder at the sight of the growing mountain of unread medical journals gathering dust on their desks over months, if not years. They need not despair though, as there are less time-consuming ways to keep up-to-date than meticulously working your way through the journal pile.

Of course, one could simply walk away from the threat posed by the information overload avalanche, cancel journal subscriptions, not buy the latest medical textbooks or ship the lot to a needy medical library. But the out-of-sight out-of-mind approach risks the doctor being left behind.

Doctors are expected to be attuned to the latest developments in health care, keeping pace with extremely well-informed patients. The rhetoric of medical research underpinning optimal health care is incompatible with the grinding reality of busy work life.

So our lassitude with keeping up to date with the latest research is, we believe, excused by busy clinical practice and the accelerating pace of modern life. And the flood of new evidence gives clinicians only a remote chance of breaking the surface and catching breath, let alone reaching the summit of the journal mountain.

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What’s more, doctors may not be able to confidently recognise and understand important and reliable developments, let alone decide on their relevance to patient care. Most remain unenamoured of the bruising and seemingly irrelevant encounters with statistics and research methods from their undergraduate years.

And after a long work day, a demanding journal article can’t compete with relaxation and family time. Serious engagement with an article is, for most of us, not conducive to rest and recreation.

Two decades after leaving medical school, my enthusiasm about the latest issue of the New England Journal of Medicine often extinguishes the fire of work tearoom conversations. Like-minded colleagues (those unshackled from the entrenched cultural disdain for research) are a rare species found only at journal clubs, teaching hospitals, medical schools and conferences.

Time constraints and apathy aside, there’s the other not inconsequential problem of discerning crop from chaff in the research. How to keep up with the latest research relevant to one’s clinical practice and verify what’s claimed by new drugs, tests and technology?

But keeping abreast of the latest research is important because doctors can’t deliver the latest evidence-based health care if they’re not aware of it. Patients benefit from doctors keeping up to date and being knowledgeable about recent studies that are reliable as well as being relevant to clinical practice.

Treatments evolve rapidly and established drugs and procedures may turn out no better than placebo. Doctors also need to be vigilant about newly discovered side-effects or harm resulting from reputable treatments.

Henry Rabinowitz

Careful scrutiny of drug-company sponsored clinical trials could lead doctors to the conclusion that exciting but expensive new treatments are not superior to reliable old work horses. Sponsored studies may ignore comparisons with long-established effective drugs (there’s little income in established patent-expired drugs).

If only doctors had the time at work (preferably paid and without clinical obligation) and the necessary skills to assess the methodological robustness of a study, decipher its findings and apply its conclusions to patients. Such favourable conditions are rarely available outside the journal club, postgraduate training, teaching hospital and medical school.

If health executives really care about research bearing relevance to patient care in ambulatory and community practice, they need to fund doctors to train in appraising the quality of what they read and pay them for the time spent keeping up to date. Better informed doctors are likely to deliver better care and dividends in improved care will likely outgrow remuneration to doctors.

Ultimately, there’s nothing better than scrupulous journal reading or attending conferences to stay in touch with the latest research evidence. But alternative strategies for the time-poor include:

• Participation in specialist college on-line continuing medical education activities or moderated clinical topic websites;

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• Attending non-sponsored local hospital medical education sessions is difficult as they are scheduled within office hours so webcasts can offer flexibility;

• Registering for e-list-servers of research relevant to their work (including abstracts and selected editorials) and e-alerts of the contents for major general medical and sub-speciality journals;

• Reliably moderated medical guidelines and texts (many available online) such as Up-to-Date, e-Therapeutic Guidelines. These circumvent the need to assess the primary studies individually; and

• Adhering to the latest treatment guidelines from learned entities such as the Acute Coronary Syndrome recommendations of the National Heart Foundation and acute asthma strategies from the National Asthma Foundation.

Burgeoning health-care evidence needs to be efficiently delivered to doctors caring for patients in digestible allotments that will not prove overwhelming. This involves communicating information relevant to their clinical practice or specialty, in a format and schedule compatible with achieving balance in a doctor’s work and personal life.

Paying doctors for non-clinical time to learn about the latest evidence is a good start. Even if one has not assessed the original studies, investigation and treatment summaries updated with newly emerging clinical research provides a short-hand way for ensuring patients receive the best of care.

Joseph Ting received funding from ARC Linkage Grant for Emregency Health Services Qld Study 2007-2011.

This article was originally published at The Conversation. Read the original article.

Reproduced from "The Conversation"

What Australia should do about prescription opioid misuse

Knowing the dose of the tablet means overdoses are less common than with heroin. d ab d z/Flickr

Consumption of slow-release prescription opioids has been increasing in Australia for about two decades. Now, the federal government has said it will set up a new $5 million national electronic records system to improve monitoring of these drugs.
The Electronic Recording and Reporting of Controlled Drugs system will be made available to doctors, pharmacists and state and territory health authorities across Australia to monitor the prescribing and dispensing of addictive drugs in real time.
Before the government moved toward national implementation, this system was tried out in Tasmania and evaluated favourably.

Consumption trends

Consumption of these drugs began earlier and increased faster in the United States. Overdose deaths from prescription opioids there first outnumbered such deaths from heroin and cocaine in 2000. That gap has steadily widened in the past ten years. And more and more people in the United States struggling with dependence on prescription opioids have been coming forward to seek help.
So we know the pattern of what would happen in Australia if we allowed consumption of prescription opioids to keep increasing. Canada and the United Kingdom have also reported similar developments to Australia.

Road to problems

Doctors prescribe opioids to treat pain from cancer, acute pain (such as after an operation or heart attack) and chronic pain not due to cancer. They’re usually very effective for the first two sorts of conditions but nowhere near as effective for the latter.
In Australia, prescriptions for opioids are obtained by a relatively small number of people who visit a large number of doctors to obtain huge quantities of these drugs. Profits from selling the drugs on the black market are very high because people who enjoy taking opioids for recreational purposes have found heroin a little harder to purchase since a heroin shortage started in Australia in 2000.
Another contributing factor to the increasing use is the growing difficulty in recent years of getting on to methadone and buprenorphine programs. There are no votes in funding these forms of treatment, even though 70% of the community now support them.
So, many heroin users have started buying prescription opioids from the black market, crushing these tablets and injecting them. Overdoses are less common than with heroin because, unlike street heroin, the dose of the drug in tablets is known.

Effective interventions

Australian health authorities have known all this for a while. But it’s a complex problem that crosses commonwealth, state and territory governments. And within each department of health, several sections have to be involved.
There’s no silver bullet but a number of strategies will help, especially if some leadership is applied to the problem. Unfortunately, leadership is a scarce commodity in Australia’s current volatile political climate, with attempts at major health-care reform taking up a lot of time.
And we are now moving to a national real-time, web-based data system for prescriptions. That will help, but efforts to stem the supply of drugs in the face of strong demand, while politically irresistible, often promise more than they end up delivering.

Important steps

Improving the treatment of chronic non-cancer pain will have to be part of the solution.
Most of this treatment is provided by general practitioners. While Australia has a surfeit of excellent guidelines for treating chronic non-cancer pain, none are written by general practitioners for general practitioners.
We also need a whole system for training allied health professionals to help manage chronic non-cancer pain with non-pharmacological treatments. But there’s no training course, no qualification and no way of funding this at present. So general practitioners will continue to prescribe large quantities of prescription opioids while treating chronic non-cancer pain.

Other options

Expanding methadone and buprenorphine treatment and making these more affordable to drug users, who generally have low-incomes, would also make the black market for prescription opioids less lucrative.
We need to develop a new treatment system for people struggling with dependence from prescription opioids. While there’s some overlap with the population using heroin, some of the people who develop problems with prescription drugs are quite different from heroin users.
A national policy for prescription opioids and benzodiazepines is now being prepared and this is a positive step since Australia has never had a policy covering these drugs. It seems ironic that these legal drugs have been ignored for so long. Many of the people who enjoy taking prescription opioids and heroin recreationally also take benzodiazepines.

Path least travel

In the alcohol and drug field, the politics of implementing effective responses are generally much more complex than working out the right public health interventions. And the cost of politically attractive policies that don’t work is getting harder to bear in an era when government budgets are stretched to breaking point.
The lesson of Australia’s heroin epidemic of the 1990s was that politicians must start getting serious when increasing numbers of deaths begin occurring among middle-class kids.
This effort by the Federal government to create a national electronic record system for prescription opioids is a step in the right direction. But unless it is supported by a range of other measures, there is a risk that it will send us backwards. Supply measures are easy to sell to the public but are often disappointing and sometimes seriously counter productive.

This article was originally published at The Conversation. Read the original article.

Lying to patients

This is a transcript of a video presentation on Medscape. Medscape is a site that requires registration and logging in, so I reproduce the transcript here to permit wider observation and discussion.

 Lying to Patients: No Huge Ethical Failure, Says Bioethicist Arthur L. Caplan, PhD

 I am Art Caplan, and I am at the University of Pennsylvania in the Department of Medical Ethics and Health Policy. Today I would like to talk to you about a pretty thorny subject and one that is fascinating because it is so ethically rich: Should doctors ever lie to their patients?

The trigger for this discussion is a study that just came out that found that doctors do lie. In fact, the study found that 20% of more than 2000 doctors surveyed admitted that they had not told patients the truth when an error had taken place. They found out that more than 10% hadn't discussed financial conflicts of interest, and 15% said they gave a rosier picture about prognosis and risk and benefit with respect to a disease.

There has been a good deal of interest in this survey, and the public and some media reports are saying that this is shocking. We expect our physicians to always be truthful; this survey apparently shows that there is a considerable amount of lying going on, withholding of the truth, and not being forthright. What's wrong? Is there a huge ethical failure going on out there among doctors and medical practitioners?

The answer is no. It is inexcusable and not advisable to lie about an error. You may dodge a bullet on that one by having the patient not find out, but if it really affects their care, if they wind up harmed, if they wind up having to pay more and it comes out later that you didn't tell the truth or that there was an omission of the fact that an error occurred, you are going to get clobbered. I have seen it again and again in courtrooms. It may seem the easiest way out, to avoid telling the truth when an error takes place, but getting it out there and getting it over with early is the best protection in terms of malpractice associated with error. It isn't lying.

With respect to financial conflict of interest, patients have a right to know about it, and it should be brought up. But a lot of patients don't care, so you can get around that very quickly. You don't have to lie or withhold information. You can simply offer the patient the opportunity to know that you see a lot of drug representatives or that you went out to dinner and learned about this drug, and they probably will say, "Doctor, I don't care. What do you think is the right thing for me to do?" Making the offer is a better way to deal with something that a lot of patients don't think is all that important.

What about that circumstance in which a better prognosis is offered than is really the case for the patient? That circumstance, and a couple of other topics, are real ethical gray zones. It is not as clear that lying is always bad. Think about the use of a placebo. If you think that you can save a patient money and save them a lot of risk and side effects by giving them a placebo to see if it will calm their anxiety or help restore their sexual function, I am not sure that it is always wrong to prescribe a placebo. It is controversial, but I am not sure one is always wrong in trying to deal with a difficult or noncompliant patient, or one who has a bad, unhealthy lifestyle.

Is it wrong to "up the ante" a little bit and scare the patient more than you might otherwise about the consequences that might follow from their bad behavior? I am not sure that that is wrong either. The goal is good, and by being a little bit on the far end of the truth about what could happen to them, I am not sure that it isn't worth it. With respect to the "rosy prognosis," if someone has cancer or Parkinson disease or Alzheimer disease, I'm not sure that they want to hear in the first visit exactly what is going to happen to them or the grim nature of the statistics.

You might say that telling the truth is a noble thing to do, an important thing to do, and it is the way that we are going to keep patients trusting the doctor. At the same time, however, truth is not an event; it is a process. The survey may have failed to capture that insight. Telling the truth is important, but letting it come across in a humane way, letting it come across sometimes in "dribs and drabs" so that the patient can absorb it and not be psychologically devastated or emotionally harmed, is the right thing to do.

So, don't lie about mistakes, don't lie about conflict of interest, and be forthright when things go wrong. When there is a reason not to be trusted, let the patient decide how they want to manage that. Truth is a better policy. In some other areas, the truth, although it ought to come out eventually, is probably something that is more of a tool to be worked with in trying to help patients than it is an absolute necessity all of the time.

I am Art Caplan at the University of Pennsylvania. Thanks for watching.

Visit the outback's mechanical victims

Visit the outback's mechanical victims - ABC Southern Queensland - Australian Broadcasting Corporation

Just a little light diversion from medical, but a look at the outback that many of us "out here" are familiar with.

Another useful post for Locum doctors

.. Here ..

Three weeks break and back to it

After a three week break and a settlement on a new property in Port Douglas (we are now officially mortgage stressed according to the stats) I return to work with three weeks of 24/7 at Julia Creek and nearly four weeks (also 24/7) at Normanton. Both places are in far north Queensland but are vastly different.

 Well ... I guess a comment on the property purchase first. Having worked in FNQ for over 5 years and especially loving the area around Cairns, and having watched the real-estate market for over three years around the Mossman Port Douglas area, I decided to make a significant life decision. Instead the option of working locums part time and relatively casually, I have effectively committed myself to working close to full time for at least another 5 years. I guess it was to create an additional purpose to the reason why one works for an income by buying a second "home away from home". Melbourne is still our home, and for quite important family reasons will remain so for at least the medium term future (if one can plan for such anyway) but a house/villa in Port Douglas gives my family a second locale to enjoy the fruits of my labours.

 Julia Creek ... in central north Queensland on the main road between Mt Isa and Townsville. A relative small town, with a 16 bed hospital built in 1972, in the middle of cattle country. A wide, open and expansive place. Two pubs in town, two small "supermarket" type stores, railway along the edge of town. Friendly people. Had Christmas and New Year in Julia Creek. I have a few photos of the area in my Project 366 album. The work was relatively quiet, apparently those who would have left town for the holiday break had already left, and others were preparing for a long, isolated stay on station when the wet hits.

 Normanton ... further to the north and much closer to the Gulf of Carpentaria, about 75km circuitous drive to the coast. I am there currently. It has a high proportion of indigenous people in town, three pubs, a couple of small "supermarket" style stores. It is on the edge of "wet country". The bird life is abundant, including the more exotic brolgas that are a delight to see both on the ground and in the air. 

The work is quite different to what I was doing in Julia Creek, including more after hours work, more hospital admissions and a twice a week trip to Karumba on the coast to run a clinic. It is now wet season and despite (at this instant in time) it not raining every day, when it does rain it is quite heavy, and add to that the water from "upstream" and the wet country being tidal, many roads into and around Normanton are now closed.

 Had an interesting experience yesterday when the road to Karumba was officially open but the 07:30 report said there was 450mm (others in the know were saying 350mm+) of water (flowing) over the bridge on the road to Karumba. 4WD only and "use extreme caution" ... well no way I was going to attempt the trip in a yuppy 4WD (a lot of these around but the high clearance work vehicles usually not supplied by Queensland Health) so my "extreme caution" measure was to not go. Council refused to authorise a helicopter shuttle (about 9 minutes flying time I am told) because the road was still officially open, so the clinic had to be cancelled.

 Interesting "tropical medicine" in the area ... learned about a few bugs I had never heard of and some I had forgotten about.

  Stenotrophomonas maltophilia causing a wound infection is not nice. I am also reminded that alcohol consumption is the bane of some remote communities and a significant reason for after hours presentation for medical treatment.

 Yarrabah from the end of February is not a happening thing, other arrangements are in place to cover the medical services from Cairns doctors on rotation. I expect this will eventually be good for the community at Yarrabah to have the "indigenous medicine naive" medicos become aware of the different needs of our indigenous brothers and sisters and hopefully temper the racism in the medical care in the larger centres.  Interestingly a recent study confirms that racism (unconscious or otherwise) is present in our medical system in Australia.

 I am currently having my locum agents (hi Sarah and Charlie !!) working on getting me a placement in Gladstone (its been a long time since I have been there) and possibly followed by work in Mt Isa (twelve months since being there). Nothing definite booked after that except just over 2 months in Uluru October - December this year.

Will chat again another time.

Cross promotion

Another rural locum blog .. a little more generic and probably designed to be more politically correct with the intention to promote life as a rural doctor, not that I need convincing but many city doctors haven't a clue what they are missing out on.

http://ruralchampions.govspace.gov.au/author/rhwa/

It has been remiss of me ...

.. and I once again find my blog languishing, but given the close knit nature of the communities I have worked in over the last 6 months it is difficult to share my experiences without risking breach of patient privacy. Not that it can't be done, it will just require more thought that just random placing of thoughts on virtual paper.

I promise, an entry with particular references to my experiences up here in Julia Creek and Normanton/Karumba will be forthcoming.

Project 366

One photo each day in 2012




Taken with iPad, photo editing software Photogene.

Link to album online here. (( link changed to public Facebook link ))