Thanks for the Memories

What a moving scene.

Because of construction on the new Stead Children’s Hospital, several of us have to move out of our offices for the next month. It gave me a chance to once again discover how much useless junk I can accumulate. It was enough to require a big blue bin on wheels. I’ve used it before. What stuff remained fit into only 4 packing boxes. My office looks pretty bare now. I imagine that’s how it will look on the day I retire. I see this temporary move as a way of getting prepared for that, so I’m ahead of the game now.

I didn’t have to take down any pictures or certificates. I don’t really spend a lot of time in my office because I’m a general hospital psychiatrist, a smokejumper putting out fires, so to speak, all over the hospital. A big part of my job is triage, as the medical students soon learn. I organize transfers from inpatient medical-surgical units to inpatient psychiatric wards, either the medical-psychiatry unit (the only one of its kind in the region) or the general psychiatric units.

Triage implies that the psychiatry consultation service is a kind of traveling  Mobile Army Surgical Hospital (M.A.S.H.) unit–meatball psychiatry. I patch them up and send them on where further healing can take place. That’s the hope. Rarely do I get feedback from my colleagues staffing the psychiatry inpatient units although when I do I really appreciate the perspective it gives me. But it’s only a part of what psychiatric hospitalists do. In a few places, the liaison part of what we used to call Consult-Liaison Psychiatry (C-L Psychiatry for short) is starting to make a comeback:

It’s a moving on which is, at the same time, a sort of moving back because that’s historically how C-L Psychiatry got started a long time ago (actually before my time, if you can believe that). And as my medical students and residents do their own moving on to the next rotation and the next stage in their journey, we are wishing each other well. The group picture is becoming a ritual, a sort of rite of passage.

Group Picture on the CL Service April 28, 2016.
Group Picture on the CL Service April 28, 2016. Now there’s a group! Those weird objects are the mascots-and I don’t mean the trainees.

Dr. Darbie Little-Cooper, the senior in her 5th year of the Family Medicine-Psychiatry residency program, came up with something even better:

Happy Last day - Microsoft Word_2016-04-29_10-31-24
Consult-teers left to right: Dr. Mary Haas (Family Medicine resident), Dr. Suchita Batwara (Internal Medicine-Psychiatry resident), Dr. Darbie Little-Cooper (Family Medicine-Psychiatry resident); can’t touch this.
Core Competency Pizza
Core Competency Pizza

I rant and rave to the trainees about our health care system and ask them to remember my affect. I’m hoping they will. However, I’m all for evidence-based medicine and the core competencies and I tell them that. On the other hand, I was a little skeptical when I got a message in my email that invited me to read a white paper entitled “Why Evidence-Based Medicine?”

“Evidence-based medicine (EBM) is an ongoing and burgeoning field that has now become the norm in today’s practice of medicine. It involves a systematic approach to clinical problems aimed at identifying strategies that work and eliminating those that do not work, are harmful, or are proven to be not beneficial based on research evidence. The white paper Why Evidence-Based Medicine? provides the background needed to successfully implement evidence-based medicine in any healthcare setting, and gives the tools required to:

By implementing these strategies, healthcare professionals will join a movement to promote consistency of treatment and optimal outcomes, help establish national standards of patient care, and set criteria to measure and reward performance-based medical practice.

  • Translate a patient clinical problem into a well-structured question
  • Phrase that question to facilitate an evidence-based solution search
  • Conduct EBM searches in national databases, guidelines, and journal articles
  • Test evidence for validity, applicability, and clinical relevance
  • Apply the evidence and evaluate its performance

For more information, please visit McGraw-Hill Education’s Professional Insights blog.

McGraw-Hill Education has created the Professional Insights blog, a community for clinical, educational, and professional thought-leaders to gather and share their knowledge. From tips on fostering better collaboration amongst teams to advice on handling budget concerns, the McGraw-Hill Professional Insights blog has the answers you’re looking for. Visit us often for the latest news, strategies, and advice.

I’m not criticizing McGraw-Hill at all; the white paper is probably excellent. On the other hand, I’m a geezer and I get a little more skeptical with each passing year. So I looked up “evidence-based medicine” for myself on PubMed and found an article entitled “Evidence based medicine: a movement in crisis?” I didn’t read “Why Evidence-Based Medicine” because when I clicked on “Download White Paper” hyperlink I got a message with my contact information on it and a notice indicating that by so doing I would be opening myself up to further messages–which I might not want. It sounded like they might be trying to sell me something so instead I read “Evidence based medicine: a movement in crisis” because I know up front it’s free. You can figure out why I disabled the hyperlinks.

I like the authors’ tone because it sounds skeptical and because they think critically about what’s happening in medicine. I wish I were as articulate as they are when I try to convey this to my trainees. I think the boxed summaries of the critical points are important to remember:

Box 1: Crisis in evidence based medicine?

  • The evidence based “quality mark” has been misappropriated by vested interests
  • The volume of evidence, especially clinical guidelines, has become unmanageable
  • Statistically significant benefits may be marginal in clinical practice
  • Inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred
  • Evidence based guidelines often map poorly to complex multimorbidity

Box 2: What is real evidence based medicine and how do we achieve it?

Real evidence based medicine:

  • Makes the ethical care of the patient its top priority
  • Demands individualised evidence in a format that clinicians and patients can understand
  • Is characterised by expert judgment rather than mechanical rule following
  • Shares decisions with patients through meaningful conversations
  • Builds on a strong clinician-patient relationship and the human aspects of care
  • Applies these principles at community level for evidence based public health

Actions to deliver real evidence based medicine

  • Patients must demand better evidence, better presented, better explained, and applied in a more personalised way
  • Clinical training must go beyond searching and critical appraisal to hone expert judgment and shared decision making skills
  • Producers of evidence summaries, clinical guidelines, and decision support tools must take account of who will use them, for what purposes, and under what constraints
  • Publishers must demand that studies meet usability standards as well as methodological ones
  • Policy makers must resist the instrumental generation and use of “evidence” by vested interests
  • Independent funders must increasingly shape the production, synthesis, and dissemination of high quality clinical and public health evidence
  • The research agenda must become broader and more interdisciplinary, embracing the experience of illness, the psychology of evidence interpretation, the negotiation and sharing of evidence by clinicians and patients, and how to prevent harm from overdiagnosis

Anyway, thanks for the memories!