Thursday, November 8, 2012

(Don't) Mind The Gap

The Gist:  Despite our best intentions and with regard to the combined literature, research, and clinical experience, we practice dated medicine.  Information disseminates and is adopted by individuals instantaneously in many other aspects of life.  Public discourse resulting from this information sharing, applied in medicine (Knowledge Translation) has the potential to improve health care...and FOAM (Free Open Access Meducation) is a promising means to tackle this problem. As a trainee, I think it's important to build solid habits and integrate this way of thinking/tackling medical learning early on.

What's the problem?  In an epidemiology class for my Master of Public Health, I was shocked when my professor declared that it often took a decade, if not more, before evidence was practiced by clinicians.  But we're so educated!
  • Gaps between knowledge/information/experience and clinical practice (1).  Medical and health care research is booming.  Things change quickly and it's difficult to stay up to date, especially if your specialty involves every organ system and environment imaginable.  What is this research worth if we can't integrate it in clinical practice to benefit our present patients?
  • Physicians practice despite guidelines or evidence favoring a different outcome (2).  We have collections and evaluations of the best evidence from the Cochrane Library and BestBets
Knowledge translation (KT): Knowledge translation is defined as the exchange, synthesis and ethically sound application of knowledge—within a complex system of interactions among researchers and users—to accelerate the capture of the benefits of research… through improved health, more effective services and products, and a strengthened health care system.”  (1)

KT tutorials:
Goals of KT:
  • Changing behavior
  • Changing health outcomes
  • Achieving both of the above outcomes in an ethical, non-coercive way.
How can FOAM improve KT?
  • Can precede national guidelines.
  • Easily accessible from nearly anywhere
    • TheNNT has a host of evidence-based reviews on frequently encountered topics.  These are frequently revised.
    • MDCalc allows one to easily calculate a score like PESI or CHADS2-VASC score in seconds.
    • Many apps for smart phones and tablets have these built in calculators as well (Medscape under "calculators" and other ones that are paid apps).
  • Asynchronous updates in literature and research at no charge to the consumer.  Continuing Medical Education (CME) can be expensive and time consuming but blogs, podcasts, and various RSS feeds allow one to access information when, where, and in the quantity one desires (I prefer mine at the gym, in the car, or during anything that involves waiting).
    • SMARTEM is a podcast that takes deep dives through the literature to assess and interpret the evidence behind various clinical practices.
    • The Skeptics Guide to Emergency Medicine (The SGEM) has a free podcast in which they address specific articles or guidelines.
  • Bridging academic and community settings, "flattening the world" (to borrow Thomas Friedman's analogy for technology and knowledge/goods dissemination).  Knowledge and experience varies across the regions (ex: see the Prehospital and Retrieval Medicine multinational podcast on procedural sedation).
    • A group of FOAM masters recently began a "Rural Masterclass," to extend and involve rural physicians in a relevant and current continuing learning endeavor.
  • Dialogue.   Individuals in the medicine field frequently debate and discuss guidelines, criteria, and "standards of care" on Twitter, blogs, and podcasts.  This frequently engenders further examination of preconceptions, understandings, and barriers to implementation of interventions/therapies.
    • At times it seems there's peer pressure to conform to how others are doing things, even if it's not necessarily the most appropriate intervention (example: prescribing antibiotics for acute sinusitis in otherwise healthy patients or failing to prescribe steroids in acute asthma exacerbations).  Discourse between professionals can function as a support system and allow individuals to troubleshoot and benefit from each others experiences in implementation.
Is there a downside to KT?
  • Medicine is not a unilateral encounter but a dialogue and decision making process with a patient. Some individuals worry that emphasis on evidence and guidelines have the potential to overshadow the individual nature of clinical encounters (4).  Properly understood, however, KT is not a trendy guise for CMS guidelines or core measures (which are designed to be coercive).  The essence of KT is to produce better health outcomes based on all available evidence.
  • Implementation is not homogenous for each system or practice.  KT involves the attitudes, knowledge base, and infrastructure of complex systems.  In fact, there's an entire journal dedicated to implementing evidence (Implementation Science).  It's pretty daunting work, but again, the FOAM community may allow for a shared learning experience in success and hardships of implementation of current knowledge.
  • Creating and disseminating guidelines do not necessarily result influence practice at the bedside.  Effective KT is the product of integration into a clinician's cognitive approach of each situation, which is not an insignificant endeavor (5). 
1.  Davis D et atl. The case for knowledge translation: shortening the journey from evidence to effect BMJ 2003; 327 
2.  Lang E, Wyer P, Haynes R. Knowledge translation: closing the evidence-to-practice gap Ann Emerg Med. 2007 Mar;49(3):355-63. Epub 2006 Nov 3 (full text)
3.   Straus S, Tetroe J, Graham I.  Defining Knowledge Translation. CMAJ August 4, 2009 vol. 181 no. 3-4 Full Text

5.  Green L and Siefert C.  Translation of Research Into Practice: Why We Can’t “Just Do It” J Am Board Fam Medvol. 18 no. 6541-545


  1. Hi Lauren,

    Super post as usual :-)

    I really think this is an important area for us to think quite hard about. There is lots of knowledge out there, but if we are not applying it in clinical practice then we are not practicing evidence based medicine.

    I agree with all of your reasons, but perhaps might ask you to think about one more, and that is the issue of authority. In the BestBets system we often talk of ABM or Authority Based Medicine, which basically means that practice is dictated by those who 'say' what is 'good'.

    So whilst you can aspire to be an evidence based practitioner it is tricky to achieve if you are a junior in the system. This is one of the reasons why I think social media and FOAM are gloriously subversive to traditional ways of changing practice and moving medicine forward.

    Stunning work,I look forward to reading more.



  2. Wow. Thinking deeply on a topic we are all informed about but not all walking the walk. Impressed with post. One thing always bothers me with these issues: knowing isn't doing. KT isn't T until it's done. How many of us don't want to believe what we already know? Dive deep into controversy- it's good for you. But do we practice even the simplest things? Hand washing is my newest crusade and it's way tougher than abx stewardship.

    1. Thank you for sharing your thoughts, I love the stimulation/challenge. You're absolutely right that knowing does not equal doing. I think many of these issues are fundamentally a result of excuses. Our hands are never "that dirty" (yeah right), perhaps we "just washed them" (when?), maybe "everyone else is prescribing X," or the "hospital has Y policy/guidelines." Our inaction or mis-action is not necessarily a product of ignorance but not using what we know (and often, justifying it to ourselves or others). Certainly a great deal for me to think on and motivation to delve deeper and in other facets...I appreciate it!