Dr. Grant, thank you for spending time with us today. I really wanted to chat with you about how you use evidence based medicine in your clinical practice. How do you help learners use it at the point of care? This is such a large topic but sometimes we just want to focus on what's practical. And really how that works. So I'm wondering in the clinic settings, if we're going to focus on the out-patient setting. What are some general principles or ways that you try to incorporate EVM in teaching with learners with you. >> Sure, thanks for having me. So in the clinic setting it's really important to engage learners to follow and practice evidence based medicine. Just obviously a very important thing that we do and we like to instill upon our learners the importance of it, is evidence based medicine. So for example my clinic, there's several things that I would do. One particular clinic I do is a preoperative medicine clinic, or a pre-op clinic. Which is helpful because it's a more focused area of medicine, where there is evidence to guide various aspects of care. When we evaluate a patient, we definitely take a complete history. We're really focused on the areas we know we can reduce the patient's risk of having a complication either before, during or after the surgery. It's often broken down into different organ systems. So for example, we'll look after the heart first. What's the cardiovascular risk for our patient? And there's been a fair amount of data looking at this issue specifically. So much so it's also been incorporated into a guideline. But learners will often say, well, the patient has this disease and this disease and this disease. What does that mean in terms of what we do moving forward with surgery? >> Mm. >> And what I can do is sort of guide them to very specific articles. I happen to know this area fairly well, so it's often that if I just guide them towards certain articles that we can discuss. If it's a topic I'm not as familiar with, then I'll simply ask the learner, why don't we look this up? Either together or on your own, look this up, come back and we can see what's out there in terms of the evidence. >> So that's neat. So let's talk about an area where you may not be as familiar with and where the learner certainly isn't. How do you help them figure out what the right question is, in a practical sense when you're sitting there talking about a patient? >> So, the clinical scenario will drive the issue at hand. You know, and we're trying to come up with a final recommendation for our patient, giving them advice on what to do next. It's often not clear what that might be. In this case, we may be judging or stratifying the patient's risk for a certain disease. Are they at high risk? Are they kind of at moderate risk? Are they at low risk? If they are at high risk, what can we do to sort of help lower that risk if possible. So that's when we streamlined the process in the clinic. Another way that sort of will help guide this that we've incorporated into some of the care we'll do in a clinic setting is actually using our electronic medical record. So we will have a template that comes up for a specific chief complaint for a patient, for example. Or even take into case the pre operative patient again, is a template to use. It guides you through questions you should be asking the patient. Because we do have evidence to support what to do with those answers, it might be easier to gather a certain question, when you're evaluating or examining the patient, with that sort of prompt on the medical record, it's a good way to sort of remind the learning, yeah, let's ask about this because it could help influence my answer in caring for the patient. >> So that's interesting. So there's a, you're very patient centered meaning that patient really drives the questions but you use technology, you use the tools for clinical care to help the learner frame the question in the right way, help them data gather. And so, it's not necessarily a separate process that you take them through. It sounds like a really integrated process. In other words you gotta enter in the data in the electronic medical record anyway. The EHR kind of helps guide them to the sorts of information that you would be looking for and then ties that directly to the evidence? Is that right? >> Correct. So we're trying to put the information in the template in the EMR that needs to be answered. That opinion on the answer to those questions how the patient respond with patient's history, or the patient's physical exam. Then you have to determine what to do with that information. So that does requires a second step, but at least you have all information you need to make the most informed evidence based answer. >> So then do they need to go out and do a separate search after that based on their question? And if so how do you guide them in that process? >> So sometimes they will. So if a patient does have a specific complaint or a problem or an issue that needs to be addressed and it's unclear as to how to do that, between the learner and myself at that time, then we'll do a focused sort of search for an answer. And there's various ways that could be done. Often during a busy clinic you don't have time to do extensive scientific literature review. But there are other resources that are available, with things like up to date for example. It often can provide the answer. A review article. Sometimes if the data's around for a long time even a textbook could be helpful. But some of the answers are not available there, and you have to do a primary kind of search. And that's not to be done sort of at that time. I mean that could be done in the future, and then come back, and discuss again, and make sure it's implemented for that patient, for future patients as well. >> Hm, so let's say you do have to go out and do a search, and it's not as easily at-hand like a UptoDate, or a DynaMed, or a practice guideline that's right there, or something in the EHR. They have to do a search. If the patient's waiting, how do you incorporate decisions that you might make right then, if you have to spend the time to do another search? >> Mm-hm, that's a good question. It'd depend on the clinic, I suppose. So if it's a clinic, such as my preoperative clinic. >> Yeah. >> Right, I do have the luxury of getting back to the patient >> also getting back to the physician that requested the council to begin with, not everything is necessarily urgent. Of course if the surgery was schedule for tomorrow, the next day, then that does put a time constraint on that. That's typically not the case. Typically the patient might not be having the procedure done for several days or weeks out. So it does give you some time if you need to look up the data a little bit more carefully and say what should I do for this patient. Now, you might not have the answers in which case, if the evidence doesn't guide towards a specific answer you might need to consult another specialist. That's commonly done too. Who might know the data better. But again if it doesn't exist there's often that sort of art that's combined with the science of practicing medicine. >> Sort of bringing sort of expert judgement combined with the best available evidence at the time. >> Exactly right, yeah. >> Which may be mixed it sounds like. It absolutely can be. >> All right. >> It can be controversial at times. >> Yeah. >> Were we striving to find the best evidence? >> Yeah. >> What's out there? There's large, randomized controlled trials, that's great. There's systematic reviews. Meta-analyses. That's sort of the best case scenario, but if you have very specific question for very specific patient issue, you might not have the luxury of having that type of data. In which case, like you say expert opinion, you know consensus statements can be helpful. Sometimes, we're relying a specialist for that. >> Yeah, well, that's, what I'm learning from what you're saying here is the nature of outpatient clinics seems very episodic, but there's also a continuity between visits or time between visits where you can actually do a more detailed and in-depth search. And sometimes, we feel as clinicians, we gotta answer it right there. But sometimes it's not available, sometimes it's controversial, you need to get more data. And it's okay to talk with the patient at that time and say we still have a couple of outstanding issues that we need to get further consultation. Whether it's through a search or through consulting other folks. And sometimes we make the decision in a week or a day or a month, depending on when we're going to see the patient back. >> Absolutely, that's the beauty of having the continuity of care with the patient. You can address all their medical issues often, all the medical issues at a single visit. You can have them back, you can make some more data over time, make small interventions, a couple changes here and there, have a patient be more aware of some symptoms, perhaps, and come back with some further information. The data collection process can take time. >> Neat, yeah >> You know, days, weeks or even months. And have the patient come back and seeing where you at and reevaluating, looking over new information that you've discovered can be helpful in treating the patient. >> That's great. Great tips, Paul. I wonder if you might spend a little bit time now chatting with me about journal clubs. Journal clubs have been kind of a staple, a hallmark, in academic medicine, probably for 50, 60 years as an educational session. And sometimes our learners are asked to participate in journal clubs either as observers or sometimes as presenters. Many of us have had to present at journal clubs as well. I wonder if you could give us some tips on how to get learners to engage in journal clubs in a way that is productive for them, a good learning experience, and good for all the other participants as well. >> Good, yeah, so like you say, journal clubs have been around for a long time. I've certainly gone to hundreds of journal clubs over the years, as a participant or actually presenting the journal article, as well as attendee of journal clubs as well. So they can be extremely valuable journal clubs. I think the key is making sure that the topic, in this case, the paper that's going to be discussed, is on target. So if there's certain topic you'll want to discuss, the journal article will be about that, and therefore your learners will be engaged. You wouldn't want a surgical learner to go to a journal club that has to do with a topic that isn't going to be about surgery at all. It is going to be helpful for them. So I just put pressure on the person presenting at our journal club to pick an appropriate paper or papers to review. Is it going to be practical to the people who are attending the journal club. But it's a great way to not only keep up with the most recent literature, typically journal clubs will focus on recent, not always, but often will also present sentinel papers that this is a reminder of why- >> The classics. >> Exactly, why somethings important, everyone should know about this particular paper. But more typically it's a way to go over some of the more recent articles that have been published. And I think they're a great way to make sure that you are up to date on the most recent literature. It gives a chance to go over why this paper was done, why they thought it was done. The method's extremely important, that's important to make sure that your learners know can this paper be used in the patients that I see in the clinic or in the hospital setting. You know, so the methods are a very important piece. And then of course, the results of the paper. Will they influence my practice moving forward? Is it confirming what I already do? Will it change what I do? Is it something new that I should be incorporating into my practice? Having that rich discussion with the people in the room over this specific article can be a very powerful way for people to learn, absolutely. >> So if you had, let's say, a half an hour to discuss a paper. Let's say you had a journal club that's an hour long, you're doing two papers, half hour to discuss a paper. How many minutes of that should be spent on presenting the paper? Itself in your opinion, when you have seen it done well? >> Some of the first part should be some background, why it shows this paper. I hope it's a better specific patient encounter that helped you to answer your question. >> Yeah, it's a specific case. >> That is not always the case, it some of the best ones I require question looking after patient x, I looked in the data, did the literature review, and found this paper that actually helped me answer the question. So a little bit of background is important. But then like you asked, specifically the paper itself, according to the nuts and bolts of the paper, if you have 30 minutes for a paper that part should be in the ten minute range, not the majority of the time. >> Yeah. >> Always allowing time for questions as you are going through the methods. Someone has a question, did they include these patients, were those patients excluded? I think that's important >> So, you allow interruptions during that- >> Absolutely, yeah absolutely, I think that is important. Journal clubs are typically more on a little more informal. >> Yeah. >> Which I think is better, to promote better discussion. Reviewing the methods in some detail, I think, is important. And of course, the results as well. >> Yeah. That's helpful. >> Yeah. No, I think journal clubs are a very good way to sort of disseminate important information, allowing discussion amongst you and your colleagues. >> Great. Well, thank you Dr. Grant for spending time with you and time with us and sharing your wisdom about your practical advice. >> My pleasure.
