I've Been Framed! My #twitterstatslesson

The Gist:  The way in which one frames a drug or intervention may severely alter the way in which one perceives the most objective information.  Patients and physicians are similarly affected by framing bias (a cognitive bias, perhaps amenable to metacognition).  The use of absolute risks and terms rather than relative terms helps mitigate this bias.  Number needed to treat (NNT) and number needed to harm (NNH) are probably better ways of evaluating interventions and testing, even though these have limitations as well.  Bookmark theNNT.com.

I have no statistics background except a biostatistics class that's part of my MPH curriculum, and attempts to keep up with SMART EM and Dr. David Newman on EM:RAP's mini JC section.  I realized we're often not formally taught to interpret and integrate bits of statistics, although the USMLE Step 2 is now beginning to attempt testing this aspect.  Thus, this stuff is important both to trainees and clinicians.  As I've begun to learn to sort through evidence and literature, I've found that FOAM delivers.  One evening, I found following conversation regarding absolute versus relative risk among some world-renowned physicians dominated my Twitter feed (only parts are listed below):

@precordialthump @karimbrohi @broomedocstrials judged by ARR, trials applied by RRR
— Scott Weingart (@emcrit) September 11, 2012

Discrepancy worse for lower baseline risk: 1% -> 0.9%. NNT = 1000.Only RR is unchanged across populations. #twitterstatslesson :)
— Karim Brohi (@karimbrohi) September 11, 2012

X in your population lowers to 9%. ARR=1%, NNT=100. But baseline risk in my population 20%. X lowers to 18%. ARR=2%, NNT=50. @broomeddocs
— Karim Brohi (@karimbrohi) September 11, 2012

NNT a flawed measure of utility:@broomedocs Say intervention X reduces risk of death by 10%. Your population baseline risk of death = 10%.
— Karim Brohi (@karimbrohi) September 11, 2012

RT @precordialthump: @karimbrohi If baseline event rate different, RCT lacks external validity & doesn't apply to your population.[No...
— Karim Brohi (@karimbrohi) September 11, 2012

@precordialthump I take your point though. The problem is that RRR is amenable to spin by those on the dark side...
— Chris Nickson (@precordialthump) September 11, 2012

So, I began to think about my own shortcomings in understanding these statistical dilemmas and figures.  I found an older podcast by the St. Emlyn's group on iTunes under "Statistics 2" to be helpful in sorting out absolute and relative risks, as mentioned in the Twitter conversation.  Then, amazingly, I stumbled upon a paper on framing the following day via Emergency Medicine Abstracts.  Apparently, I had good reason to worry...

We frame things constantly, providing a context for information and a means of understanding the information.  Like most things, this has both positive and negative implications.  For example, when one is trying to admit a patient to a particular service, one might phrase things rather differently than when one tells a patient why you plan on discharging them.  Oftentimes we use paternalism or the legitimate best interest of the patient to justify these 'frames.'

However, pharmaceutical companies do this as well through well-crafted consumer (and provider) advertising.  For example, this advertisement states that Pradaxa (dabigatran) reduced stroke risk 35% more than warfarin.  Thus, individuals may believe that the drug will reduce their stroke risk by a similar amount.  However, the 35% reduction in stroke risk only existed for a subset of patients.  Patients and populations are heterogeneous so these numbers don't necessarily apply any given patient.  As a pretty well educated bunch, health care providers should be really good at detecting framing differences and less susceptible to this bias, right?  Wrong!

The Paper:  Perneger T,  Agoritsas T.  Doctors and Patients’ Susceptibility to Framing Bias: A Randomized Trial.  J Gen Intern Med 26(12):1411–7

• Sent questionnaires to physicians and patients recently discharged from the hospital asking the respondent to judge the efficacy of a new drug based on the information provided
• Information on the new and old drug was identical but presented in only one of the following ways:  
• Absolute mortality:  with the new drug, 4% died by the end of the study versus 6% for those who received the old drug
• Absolute survival: with the new drug, 96% lived versus 94% who lived with the old drug.   Least favorable reviews of the drug by both groups (Physicians 51.8%, patients 51.7%, p=0.98 between groups)
• Relative mortality reduction:  of those who received the old drugthose that got the new drug had their mortality reduced by 1/3.  Both patients and physicians presented with relative mortality reduction perceived the drug most favorably (Physicians 93.8%, patients 89.3% p=0.11 between groups).  The odds ratio (OR) of a respondent perceiving the drug more favorably with the information presented in this format compared with other formats was 4.40 (95% CI 3.05 – 6.34, p<0.001)
• All three presentations of risk.  with the new drug, 96% lived, 4% died versus 94% lived, 6% died  with the old drug, so those that got the new drug had their mortality reduced by 1/3
• Physicians were also tested on the NNT (50) and the relative survival extension.
• Doctors responded to the presentations with no statistical difference from the patients. OR of Doctor (versus patient) = 1.06 (95% CI 0.87 – 1.29, p = 0.55)
• The notion that information presented in relative terms rather than absolute terms is more favorably received is not new (1).

There is so much to learn from the ever-relevant FOAM world.

References:
1.  Malenka DJ, Baron JA, Johansen S, Wahrenberger JW, Ross JM. The framing effect of relative and absolute risk. Journal of general internal medicine. 1993;8(10):543-8.

FOAM Party! (The Future of Medical Education)

The Gist:  Free Open Access Meducation (FOAM, #FOAMed) is essentially a personalized, continually expanding medical curriculum that embraces an individual's attention deficits, evolves as one learns, encourages active learning, and pushes the bounds of one 'ought' to know.  Here's a good summary of FOAM.  Life in the Fast Lane has an extensive list of FOAM resources and there's a new FOAM search engine. 

What is FOAM?  Dr. Mike Cadogan and those at Life in the Fast Lane founded the FOAM initiative and continue to build, encourage, and curate FOAM on the web.

Each day, I try to spread FOAM among the other rotating medical students, residents, paramedics, and attendings.  I talk about blogs and podcasts, refer people to Dr. Mike Cadogan's video on FOAM, and, if at all possible, try to have the individual set up GoogleReader or an iPhone/Android/iPad app while I'm there.  Although this may occasionally make me appear nerdy (which is clearly not the case) or overzealous, the rewards are excellent and manifest when an individual returns with, "So, what other blogs should I follow?" or "I used _____ on shift yesterday that I heard on one of the podcasts."  It's amazing how quickly people get hooked!

Some individuals are skeptical or ambivalent towards FOAM, perhaps unaware of how this broad collection of resources can translate into real world clinical knowledge or wary of the time investment  (note: it actually increases efficiency!).  I can't comprehend why anyone would not partake in this amazing medical education outlet if they actually comprehended the intellectual benefit, personalization, and efficiency of FOAM.

I can't articulate the concept of FOAM adequately in the rare minute of downtime in the ED (hence the reason for this blog entry).  In the hopes that others buy into  the FOAM concept, I am compelled to share how the ways that FOAM is transforming me into a better future physician.

How does FOAM work for me?

Twitter - I used to scoff at this form of social media, but I became a convert a few months ago.  Since that time, this venue has proven to be incredibly useful.

• Virtually attend conferences.  I've "attended" EM conferences around the world, including Society of Academic Emergency Medicine (SAEM), International Conference of Emergency Medicine (ICEM), and multiple locally based EM conferences (NY, CA, Australia, etc).

Celebrating ICEM 2012, held in Dublin, from the United States

• Discover new content.  I used to think I had an extensive blogroll, but Twitter continuously expands my list.  Individuals often tweet links to journal articles, videos, and blogs and following.  This allows one to "read" more extensively than one would otherwise.  It's impossible to keep up with the copious amount of medical literature published, but Twitter helps with this as it's a portal into what others are reading and their take on the article/issue (intellectual voyeurism made incredibly simple)
• Active learning.  
• Distilling an idea or message into 140 characters is tough, but definitely forces one to be mindful of the core content.
• Twitter allows one to engage in conversations with individuals across the globe.  This engenders collective problem solving, brainstorming, and debate.  One can learn to think critically about clinical practice and literature.  Recently, a Google Hangout journal club-esque event was organized and publicized via Twitter with EM/CC heavyweights.
• Virtual pimping.  Several people tweet "Question of the Day," including @Radiopaedia - on imaging, @jvrbntz - based on Academic Life in EM's Paucis Verbis cards, and @EMEducation.  These are useful to test knowledge, but also often spark debates and conversations.
• Diversify.  Medicine and EM exist outside of the confine of one's nation.  Learn what's going on across the world and track global trends and thought in medicine.  
• Build professional relationships across the globe.

Podcasts - These are truly gems of FOAM, allowing one to listen to lectures and conversations from world renowned physicians and speakers at one's leisure. Learn more about them in this post, dedicated to podcasts.  

Blogs - FOAM blogs are the personalized, up-to-date textbooks of this century.  They deliver information and insight with one's own interest and goals as a filter.  Choose what you interests you, and see how quickly your interests are broadened.  A comprehensive repository from LITFL.  All about FOAM blogs.  

Videos - There's a plethora of 10-15 minute videos, packed with incredible medical education, on the web. Many of these are tweeted out and EMCHATTER also has a searchable database with summaries.

• Both Vimeo and YouTube have a cornucopia of medical videos.  Many of these are disseminated through tweets and blogs (Ex: Videos from the Society of Academic Emergency Medicine (SAEM) conference, LITFL).  
• Weekly ECG cases from ECG master Dr. Amal Mattu  
• HQMedEd.com -Excellent brief videos from Hennepin Medical Center's EM department on a wide variety of EM topics.  Updated frequently with new videos (can subscribe via RSS)
• SonoCloud.org has tons of free ultrasound clips

Questions - The Global Medical Education Project (GMEP) - is an evolving question bank that is interactive and fun.  

It seems that whenever I encounter a topic on a podcast or blog that seems esoteric or uninteresting, I invariably encounter the scenario in the clinical setting. I feel compelled to share a few examples of recent intersections between my clinical experiences and the #FOAMed world.  Just a few examples:

Pimping made easy:

•  On 8/26/12, I skimmed over the blog "Mushrooms in the Valley" from the St. Emyln's blog.  The post was on Morel-Lavallee lesions, something I barely filed away in my brain as esoteric knowledge.  On 8/28/12, my second day of a new rotation, my attending pimped me on Morel-Lavallee lesions and I was able to answer without pause.  Can FOAM predict the future?  I'm pretty convinced.

A self-built curriculum:

• On 8/27/12 and 8/29/12, I wrote on metacognition and cognitive bias.  Days later, Dr. Michelle Johnston of LITFL posted an outstanding case based blog on cognitive error.  The FOAM world supplemented my curriculum on cognitive error and clinical decision making in real time!  Then, Dr.  Javier Benítez posted a piece on Academic Life in EM on diagnostic tests and asking the right questions.  Ask and ye shall receive (or, an example of availability bias).

Improved clinical skills resulting in tangible outcomes (a few examples as I can no longer quantify what FOAM brings to the table):

• The Cunningham technique from ERcast to successfully reduce a shoulder dislocation without pain medication
• A solid ocular ultrasound curriculum from the Ultrasound Podcast and SonoSpot allowed me to confidently diagnosis my first retinal detachment (and as a mac-off detachment, at that).
• Countless discussions with patients on risks and benefits of diagnostic imaging in which I can talk to patients and physicians in terms that each understands (thanks to SMART EM and Duke's Emergency Medicine talks on iTunes).

Improved clinical skills that I use on a daily basis:

• EMBasic's podcasts on various chief complaints have allowed me to assess patient's quickly and confidently present a solid differential with an accompanying plan.  I no longer get nervous/try to avoid the charts with a chief complaint of "dizzy."  
• Employing evidence based medicine in everything from strep throat treatment to resuscitation (credit to innumerable pieces of FOAM).

Improved "book" knowledge.  I've used FOAM since just prior to entering medical school to supplement my education.  As a clinically based learner, many FOAM sources make it easy for me to absorb the pathophysiology behind disease processes.  Although I'm a trial of n=1, podcasts, blogs, and Twitter have allowed me to study at the gym, in the car, or while walking/waiting in lines.  This has allowed me to maintain a "life" outside of studying.

My FOAM journey