Wednesday, 17 August 2011

Evidence is to be applied not overlooked

Dear Readers

It's been a while since I last wrote on the blog. Many of you probably thought I had forgotten about it. Quite the contrary, but I have been very busy with other things though. I will continue to write on here from time to time but with no guarantees when.....sorry :-)

I wanted to talk about the use of evidence based medical practice in every day medicine.

Many physicians talk about evidence based medicine and it's importance in modern day medicine, but when it comes to actual patient care, some do not apply it stating variously that "in A country we do x,y,z treatments instead". That is not to say that the local treatment(s) is/are wrong, but without evidence to support it's use compared to well established medicines or procedures that do have a body of evidence, how can the local treatment(s) surmount evidence based treatment?

In many instances a senior has decided the treatment based on what they were taught combined with experience based practice. Hence, "if it ain't broken then why try and fix it?" Well, the use of EBM provides the best current established methods that can support the physician to provide medical therapy in the best possible manner. Of course, such treatment may be very different from local established therapy but that does not mean it should not be utilized.

Many physicians wish to remain in a comfort zone of practice of not using a new treatment method because of fear of it causing a problem, inexperience in the use of drugs or procedures, and fear that they will not get support from their fellow colleagues who may only be practicing "eminence based medicine". The fear of the unknown is a strong emotion to stop us moving forwards as physicians to provide the best possible treatment.

For example, it is said that amiodarone use in Japan is minimal for the "fear" of the side effects, which in the acute phase of use are actually minimal and in the long term can of course cause problems, but on minimal maintenance dose, such side effects can also be limited. The fear of never having used it, for example in atrial fibrillation, instead translates into the use of class I cardiac drugs that have inherent dangerous side effects such as proarrhythmia induction or class IV calcium channel blockers that can cause worsening systolic failure in patients with existing ventricular dysfunction. These decisions may not be optimal, but it is fear of the unknown that causes such paralysis in medical decision making leading to the use of treatments that may be inferior to those used in best practise.

It is also said that in episodes of benign paroxysmal positional vertigo, patients in Japan are given intravenous bicarbonate. When challenged about the evidence for the use of such treatment, some doctors can be vague and use the standard dogma of "this is standard therapy here" without being able to provide firm evidence for the benefit of such therapy. Evidence based texts e.g. UpToDate, can provide the current standard of therapy with references that one can rely on to make clinical decisions rather than resorting to old therapies that have not been critically tested in large trials.

The fear of providing pain relief to patients is another example leading to paralysis of clinical decisions. Severe pain may not be amenable to the usual acetaminophen or NSAIDs. Sometimes the only treatment that can lead to adequate pain control can be opioids/opiates. There is again a strong fear factor that patients will become addicts or that they will stop breathing. This can sometimes translate into patients without cancer being refused adequate pain control, which may be severe, or patients with cancer being underdosed, because of physician fear.

The laws controlling the use of narcotics in Japan are very strick having been produced over 50 years ago and which need a significant overhaul for treatment of modern day patients. It is said that only patients with cancer can have opiates and even then, some physicians need a special license to prescribe it. The fact that patients in severe pain do not stop breathing with opiates is a testament that when used appropriately, they are safe. Moreover, use in the short term e.g. acute myocardial infaction and postoperatively, there is no induction of addiction. The fact that the opiate use in Japan is 1/7 that of the UK despite it having comparatively double the population, reflects the aversion of it's use in the medical community generally.

The use of EBM can help to support the physician to make difficult decisions when their experience base runs out. A physician should always recognize their limitations. If they are unable to answer the question themselves, they can ask for a specialist opinion or they can go to the books. However, the books are only as good as the time of when they were written and usually, by the time they go to print they are already out of date! Therefore, utilizing an EBM database that is updated regularly must be the best current way to answer difficult clinical questions.

One should also bear in mind that EBM texts are not just there to help with therapy. They are produced to aid the physician to consider differential diagnosis to try and prevent premature closure of diagnosis. In the early stage of an illness with few symptoms and clinical signs it can be difficult to be specific about a diagnosis. Such texts can help guide the physician about the natural history of disease and atypical manifestations and presentations. This can be very valuable as no physician can hold mountains of information in their minds ad infinitum. With the ever changing world of medicine and epidemiology of diseases over time, an updated EBM text can be a very helpful assistant.

It should never be an embarrassment to not remember something, but it is an embarrassment and sometimes negligent, if information can be checked but it is not done so because of pride of supposedly "knowing everything I need to know". From my own perspective, the more I read to keep updated, the more I realize that I know even less. I end up with more questions that when I started.

I shall no doubt be writing more on this in the future.

Essentially, there is no excuse to avoid the use of EBM at the bedside to assist in patient care. EBM can answer many of the clinical questions that come up everyday on the ward. The fear of the unknown and uncertainty is something physicians must deal with everyday. There is no escaping it by ordering more and more tests, and which "play for time", and which are unlikely to answer the questions.

As a word of warning, the use of EBM in a patient with for example, X disease, should lead to the use of that same evidence and application of it for all future patients with X disease (but by also checking to make sure the EBM recommendations are still the same or have been updated) rather than it being an isolated case or an "experimentation with EBM".

We as physicians need to keep as knowledgable as possible about the changes in medicine and by reading thoroughly we can increase our comfort zone of knowledge by applying this to patient care at the bedside rather than being fearful of the "unknown" and "personally untested". We should embrace EBM to provide the best possible patient care.

Reading EBM is good but applying it in reality is the only way to improve patient care otherwise we have a situation of "one hand clapping". Without two hands i.e. Reading and applying what was read, we will make no clapping noise and as a result, patient care will remain unchanged.

Please consider.....

Friday, 28 January 2011

Rounds around the computer are not rounds

Dear Bloggers

It's been a while since I last wrote on this blog. I'm afraid I've been very busy but I nevertheless have not forgotten about the blog.

From my experiences in Japan, patients are often discussed around computer terminals with much emphasis given to laboratory data and radiology rather than the history and examination. This is nothing new to this blog but the fact that the patients are seen for just a short time and given a cursory examination, is not what I would classify as a clinical round.

In other countries such as USA, Australia and the UK, although there is also discussion about data and scans, their emphasis is not put before the history and physical examination of the patient.

Clinical interpretations, decision making, treatments etc are based upon the combined picture of all elements including what was or was not found in the history and on the physical examination with the addition of basic tests e.g. blood tests, ECG, chest x-ray. Decisions are not based only on tests. In the emergency situation, withholding treatment while awaiting test results can end up with a dead patient. For example, a tension pneumothorax is a clinical diagnosis and sending the patient for a chest X-ray would be viewed as malpractice and even incompetence. A needle thorocotomy at the bedside is a diagnostic therapy and fully justified in such a situation.

When reviewing patients on the ward rounds, clinical signs need to be re-elicited to determine if there is a worsening or an improvement. It is not often necessary to keep repeating laboratory data daily (unless the patient is very unwell) or 'following the X-ray' or perhaps more commonly, 'following the CT'. One must remember that patient signs e.g. crackles of pneumonia, can disappear before the radiograph resolution. Hence, following a scan may prove to be less accurate than the physical examination. One must actually 'follow the patient' and not waste time with unnecessary, costly, tests when simply percussing, palpating and listening can tell you if there is an improvement or not and without cost.

On ward rounds, unwell patients need daily physical examination or even more frequently if the clinical need arises. A simple few words and a wave is not sufficient. It does not tell you what is going on with the patient. Moreover, laying on of hands is invaluable as it tells the doctor sometimes more information than a blood test or an xray. In addition, patient satisfaction is better because it shows that the medical staff are actually interested in finding the problem.

There have been situations when a full physical examination of the patient has resulted in the patient developing a 'welling look' and comments including 'I have never been examined in such detail before. Thank you.', 'I've been in hospital for many weeks and this is the first time I have been examined properly'. Family members are also highly satisfied if the medical staff show real interest and examine.

In addition, although it is not commonplace for medical staff to ask many questions as it is viewed as a kind of 'rudeness' to inquire and can be embarrassing, that kind of way will result in diagnoses being missed as the question(s) was/were never posed. Better to ask more questions by asking 'why' than be scolded by a senior doctor later with them asking you 'why not !'

Hence, ward rounds done on paper / electronically of course have their place, but they should not be the only component of a ward round. Patients need to asked more questions to help narrow down the current problems and physical examination should be performed for reassessment.

All conversation information and physical examination needs to be properly noted (under subjective and objective in the SOAP format of notation) at the time it takes place and not hours later. Remember that such information is the basis of a legal document and if not written down immediately, essential information can be and is often missed. This can lead to inaccuracies and wrong tests / treatments being ordered or not ordered at all.

Treatments need to always be re-evaluated. Antibiotics, dose, frequency, side effects, and the patient response to such therapy needs to always be considered. Moreover, rather than just starting antibiotics and forgetting about the stop-date, such treatment always needs to be revisited to decide on when to complete the course. If the patient does not respond appropriately, there can be several reasons which need to be considered:

1) The antibiotic is not covering the organism(s) e.g. anaerobic bacteria
2) The dose / frequency is too low
3) The patient has immune suppression
4) The bacteria has resistance to the antibiotic
5) A non-bacterial cause is present e.g. pulmonary embolism, vasculitis, fungal infection
6) A collection has formed e.g. lung abscess, valve ring abscess, sub-phrenic abscess
7) There may be a drug-fever; patients need to always be asked if they have ever had a reaction to drugs with antibiotics being a particularly common problem
8) There is a line infection e.g. prolonged use of central lines causing candida bacteremia

Hence, simply switching to a 'napalm-kill everything' carbapenem that kills indiscriminately is not always the answer. The bacteria may be very sensitive to the original antibiotic e.g. penicillin, but it may be one or more of the above elements that is resulting in failure of resolution. Switching to a 'penem' will of course be useless if there is candidemia, abscess formation, PE.

Carbapenem usage should not be first line except in certain situations e.g. neutropenic sepsis. Because antibiotics are strictly managed by microbiologists, pharmacists and infectious disease doctors in places such as the UK, Australia and the USA, carbapenem use is far less. In many situations, it is 3rd or 4th line but almost never first line.

Hence, evaluating where infection may be coming from rather than pumping in a 'penem' and hoping for the best is essential to ensure that the patient is receiving appropriate care.

As I have mentioned, commencing antibiotics needs deep consideration but stopping them is also a very important thing.

The usual way of stopping antibiotics is when the clinical features and (e.g. symptoms and signs), vital signs improve e.g. fever resolution, the patient feeling better, and with the hematologic parameters returning towards normal, which is sometimes not practiced in some institutions. Patients are sometimes maintained on intravenous antibiotics for weeks on end even though the patient is well, mobilising, eating and drinking for the mere fact that the C-reactive protein (CRP) is still elevated. I have heard of a case in a university hospital, whereby a patient who was well post-surgery had an elevation of the CRP and which was the sole clinical indication to re-operation. This way is not advocated. The CRP is indeed a better indicator that the laboratory is open.

When making clinical decisions, all elements must be taken into account and not a non-specific lab test.

Of course, infection causes inflammation, and even after the bacteria have been eliminated, the inflammation may persist for several days or even several weeks thereby elevating the CRP. But if the patient is feeling better, fever, signs of sepsis have resolved and other parameters are returning to normal, there is no indication to continue intravenous antibiotics. They can be switched to short-course oral treatment or even discontinued depending on the clinical situation. Exceptions are for chronic or difficult to treat infections such as osteomyelitis and endocarditis that require many weeks of antibiotics. However, for an uncomplicated pneumonia or a urinary tract infection which are exceedingly common, short course antibiotics with clinical reevaluation and early de-escalation is best to avoid prolonged hospital stay, reduce antibiotics pressure on bacteria and to reduce cost to the patient.

Remember that if a patient is on drugs that could be causing worsening of their condition e.g. ACE inhibitors, anti-psychotic drugs etc, they should be stopped to evaluate if they are the cause and to observe for resolution. An excellent resident recently keenly noted that in a patient with an FUO for 6 months, that all investigations offered up no cause. Only on instituting a 'drug holiday' of stopping all drugs, did the fever abate, inflammatory markers rapidly dropped and patient could eat and mobilize!

I can't emphasize enough the importance of bedside history taking, re-evaluation by physical examination, and re-evalautuon of drug treatments etc. Clinical examination can avoid the 'follow the CT' reflex and avoid radiation. Your patients will be much more satisfied that you've taken the time to lay hands on them to evaluate them than sending them into the 'tube of truth' to come out empty handed.

However, as a word of warning, if you do find an abnormal clinical examination e.g. unequal pulses and BPs in a patient with central tearing chest pain, the physical exam directs the physician to obtain appropriate scans and institute life saving treatment.

Without the tools of history and physical examination, we as doctors are shooting in the dark and using a sledgehammer to crack a walnut with routine CT scanning for simple pneumonias that can be diagnosed simply by traditional methods and a simple X-ray. Without the basic tools and over-reliance on the 'machine', we end up slaves to the machine and practicing defensive medicine when no such defense is necessary or warranted.

In the end, it comes down to clinical reasoning which can only be learned from experienced staff adept in managing the many conditions that medicine throws at us on a daily basis. The PC is not a patient and cannot speak or elicit signs. Better to go to the bedside. The patient will tell you more than any book or webpage.

Please consider.....