Unlearning - Yoga For Your Brain

The Gist:  Knowledge translation is a problem in medicine and, at the individual level, unlearning likely contributes to the knowledge translation gap.  It may also exist as part of the solution. Akin to yoga, unlearning requires flexibility, training or deliberate practice, and is enhanced by a community open to skepticism and growth.

• Note: These musings are not evidence based but are more of a cognitive framework to understand why we have such difficulty individually changing practice.

For an introduction to unlearning, check out this post.  In brief, unlearning, while really an aspect of truly understanding and learning, is complicated.  Most of us find it relatively easy to stuff more information into our brains, a process we perceive as "learning."  Nasal cannula with oxygen at 15 liters per minute plus may help prolong safe apnea time and reduce hypoxia during intubation?  Cool, we can do that.  However, when we are told that something that we routinely do or believe may not necessary or even harmful, we often have more difficulty changing out behavior or "unlearning." Intubating patients with out of hospital cardiac arrest may not be helpful? Preposterous! Unlearning a bit of information is unnatural, it may feel awkward whereas learning, as it often does not put our knowledge or ego in jeopardy.

Flexibility - Unlearning requires cognitive flexibility. When we stretch our bodies, we reach a point where we feel a burn; our body telling us we are approaching our limit. We can push further safely, it just burns slightly more.  Unlearning is essentially the same and is often accompanied by “the burn.”  When we come across information counter to the way we practice, it stings. We may feel defensive. This is “the burn.”  We experience discomfort when we stretch our thinking beyond this. This may be, in part, because we are emotionally tied to our knowledge. We work hard for what we know.  We act quickly in emergency care and must have confidence in what we know, as emergent situations do not typically allow for debate or significant time to think.

• A fix: When one feels “the burn” when confronted with new information that runs counter to our practice, recognize that this is a warning sign that knowledge may be changing.  Recognize that the sting comes from our ego, protecting what we know.  This does not mean that one should change practice whenever we come across a piece of novel information. Rather, we should we aware that in order to practice evidence based, up to date medicine, we may feel discomfort. When our beliefs are challenged, instead of becoming defensive, we should thoughtfully consider the information.

Training - Mastering a yoga pose requires training and deliberate practice. In order to unlearn ways of thinking, we must also engage in mental preparation and practice.  It is easy, particularly in emergency settings when adrenaline dominates, to think and execute in a perfunctory manner. We default to what we know and what is familiar.
Some fixes:

• Early Exposure - The earlier we begin training, the more prepared we are. If one has an upcoming race, we may expect we will perform better if we begin preparing earlier rather than the week before the race. Similarly, when it comes to unlearning a habit or a way of thinking, the sooner we are exposed to the contrary argument, the more prepared we may be to unlearn.  This may serve as a preconditioning so that we may react less strongly upon repeat exposure. 
• Repeat Exposure - Practice is central to most athletic endeavors. The more repetitions we do, the stronger we become.  The more we practice a yoga pose, the more likely we are to be successful, the more comfortable it will feel.  Unlearning is easier when we are exposed to the target bit of knowledge more frequently.  Spaced repetition exists as one of the most evidence-based means of learning and  this probably applies to unlearning. 

Community - Yoga and CrossFit are associated with strong communities, as are many team sports.  Communities may motivate us, hold us accountable, and push the bounds of our perceived capability.  Studies demonstrate that physicians practice similarly to the institution where they trained and show a wide array of geographic variation in practice patterns. A network of peers and colleagues, particularly outside of own’s main “system” or hospital, may increase our cognitive flexibility by exposing us to a wide array of practice pattern.  The Free Open Access Medical Education (FOAM) community may expose to novel and controversial information.

Unlearning in the Prehospital Arena: The Workout

Needle Decompression for Tension Pneumothorax (see this post or this podcast).  The second intercostal space at the midclavicular line (2nd ICS MCL) has been taught as the ideal spot for needle decompression.  This, however, is changing.  New recommendations are to use a catheter at least 8cm in length if needle decompression is attempted at the 2nd ICS MCL or decompress at the fourth or fifth intercostal space at the anterior axillary line (4/5th ICS AAL).
The chest wall is thick at the 2nd ICS MCL [1,2].  Radiographic studies of chest wall thickness demonstrate increased thickness at the 2nd ICS MCL compared with the 4/5th ICS AAL (4.78 cm vs 3.42 cm).  Even ATLS states that needle decompression in the 2nd ICS MCL will fail more than 50 percent of the time.  This is an intervention undertaken in extreme circumstances in critically ill patients.  A chance of failure of 1 in 2 is unacceptable.
The 2nd ICS MCL is difficult to identify [3,4].  The clavicle extends further than most people think. As a result, providers are less accurate in identifying the 2nd ICS MCL compared with the 4/5th ICS AAL.

The pulse check.  If one were to survey cardiac arrest resuscitation across the United States, in and out of hospital,  we would probably see that the majority of people pause every two minutes for a “pulse check” despite decreased emphasis on the pulse check by the AHA guidelines over the past 10 years.  The guidelines recommend minimal interruptions for pulse check and detail the problematic sensitivity and specificity of pulse identification [6].  After the initial pulse check prior to CPR, the guidelines don’t actually specify any time frame for repeat pulse checks. Yet, many of us do.  Sure, we can pause for rhythm analysis; however, many systems and the European guidelines now recommend pulse assessment upon observation of an organized rhythm or increase in end tidal capnography [7].
Few people can determine the presence of pulselessness in 10 seconds. Dick et al of patients placed on cardiopulmonary bypass and providers blinded to whether or not the patient actually had a pulse. Only 2% of this cohort of experienced providers were able to identify a pulseless patient in 10 seconds [8]. With increased emphasis on compression fraction, this may result in a delay in resumption of compressions.
The accuracy of the pulse identification by providers is suboptimal, noted to be 78% in one study [9].  While an accuracy of 78% may seem high, this means that approximately one in four times we will be wrong. We may feel the reverberation of our own pulse and the truly pulseless patient may have an unnecessary and perhaps deleterious delay in chest compressions.
For more on this topic check out this post and/or this post.


Left Bundle Branch Block (LBBB) as a STEMI Equivalent (check out this post)- Prior to the 2013 iteration of the AHA guidelines for ST-elevation myocardial infarction (STEMI), new or presumed new LBBB existed as a “STEMI equivalent.”  This often activated the cath lab and STEMI teams.  In 2013, the AHA removed this from the guidelines yet these patients are often referred to the emergency department for “rule out MI.”
Further, STEMI may often be diagnosed on ECG, using the Sgarbossa or modified Sgarbossa criteria (link) [10].

Backboards - fortunately protocols in many states and systems have dispensed with long backboards.  Long thought to be protective, despite known harms, the American College of Emergency Physicians released a guideline in 2016 explicitly stating that long backboards should not be used as a therapeutic or precautionary measure. They cause harm and don’t help. [11]

Oxygen in Acute Coronary Syndromes - Aspirin, oxygen, and nitroglycerin have long been the initial interventions for patients with suspected ACS. Recent studies have found no clear benefit for oxygen in patients with normal oxygen saturations. Further, one study found oxygen was associated with markers of larger myocardial infarctions (although this is not a patient-oriented outcome) [12]. The AHA recommends oxygen is appropriate for patients who are hypoxemic (oxygen saturation < 90%) [6].

References:
1.  Laan D V., Vu TDN, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2015:14–16.
2. Advanced Trauma Life Support, 9th edition.
3. Ferrie EP et al. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J 2005;22(11):788–9.
4. Inaba K et al. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers
5. ACS COT
6. Berg RA, Hemphill R, Abella BS et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 122(18_suppl_3):S685-S705. 2010.
7. Resuscitation. 81(6):671-5. 2010.
8. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse?Crit Care Med. 2000 Nov;28(11 Suppl):N183-5
9. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation.
10. O'Gara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology. 61(4):e78-e140. 2013
11. "EMS Management of Patients with Potential Spinal Injury." ACEP Board of Directors. Available at: https://www.acep.org/clinical---practice-management/ems-management-of-patients-with-potential-spinal-injury/
12. Stub D et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 131(24):2143-2150. 2015.

The (Un)Learning Process

The Gist:  Despite Harvard's medical school dean, Dr. Burwell, warning students, "Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which," medical education doesn't do a very good job preparing us for unlearning the wrong half.  Recent publications revealing the reversal of common medical practices demonstrate the need for this skill among clinicians [1-4]. Although unlearning is a part of the learning process, it is difficult, can feel personal, and may mirror the stages of grief [6].  Recognizing the obstacles to unlearning and arming ourselves with an enhanced awareness of ways in which we can overcome these barriers may mitigate our difficulty unlearning.

A study by Prasad et al examined studies testing the "standard of care" in publications in the NEJM and found that 40.2% of articles testing a practice that existed as "standard of care" reversed the practices, whereas 38% of articles testing the practice reaffirmed the standard [1].  The follow up commentary demonstrate that physicians should be open to unlearning and should treat studies with skepticism [2,3].  This is not to say that trainees and physicians should perform full, independent critical appraisals of each article they read but rather, beware of the barriers to scrutinizing our practice.  Through Free Open Access Medical Education (FOAM), one may keep a finger on the pulse of medical literature, through the primary literature and voyeurism into how others process the information.

The Case:  I read the Nielsen et al paper on therapeutic hypothermia (TH) in cardiac arrest in the New England Journal of Medicine with astonishment after the FOAM world exploded with chatter on the paper.  Just days before, the residency conference featured a presentation outlining the evidence behind TH, including the landmark papers by Bernard et al and by The Hypothermia After Cardiac Arrest Study Group.

@BaystateEM @LWestafer largest RCT on THT out today! Hmmm http://t.co/wcOLju07Gh
— Sukh (@sukhsingh927) November 18, 2013

This paper made me feel uncomfortable.  Medical school, Rosen's, and Tintinalli's made no mention of this aspect of medicine - how to unlearn something well ingrained. This is not to say I think we need to unlearn TH, but to re-examine the cherished practice to identify parts that create a difference in patient care. Less than one year into my residency, there have been countless interventions, diagnostic algorithms, or pathophysiologic explanations, taught to me as a medical student, that are now widely accepted as untrue or bad practice:  activated protein C in sepsis, the pathophysiology behind the hypoxic drive in COPD, the new left bundle branch block in a not so sick patient. I am not an expert, but these struggles with unlearning (or relearning) caused me to develop practices to keep my mental flexibility in check.

Stages of Unlearning and Practices to Overcome These Barriers

1.  Denial - We gravitate towards literature, dogma, experts, and practice patterns that reflect our own biases.  Thus, we may not come into contact with the information prompting a change in our practice or, alternatively, we may outright dismiss the assertion or data without a solid look.
Action:

• Remind ourselves that publications may lead us astray if we are not careful [4,5].  
• The first study makes the biggest splash but the second (third, fourth, etc) are the most important - don't overlook these [4].  After all, replication is the key to science, the foundation of medicine. 
• Pay particular attention to "negative" studies, which are published far less frequently than positive studies.
• Statistics may be easily manipulated.  This exists as data dredging, too much reliance on clinically meaningless statistics such as the p value, or misrepresentation of data or statistics in conclusions [4,5].   
• Stay abreast of current literature which may include using others to help curate and manage the influx of evidence Examples in FOAM, such as use of Twitter, Emergency Medicine Literature of Note, Richard Lehman's Journal Scan, EM Nerd, can be found at the end of this post. 

2.  Anger - We tend to become defensive when our beliefs and practices come under scrutiny or are challenged - it can feel like we're being attacked.
Action:

• Accept that we will do things that may, in hindsight, be called "wrong" even though this was not known at the time.
• This takes a certain level of intellectual and emotional vulnerability.  Historically, this is not only an issue at the individual level, but also a barrier for institutions to unlearn a practice [6].  
• Reassure ourselves that medical interventions do not define us as providers.  Recognize that evolution of medical practice involves a continuous state of learning and unlearning, despite our best research and efforts. Do not take individual medical interventions personally; rather, attempt to take our overall commitment to good, patient-centered medicine seriously.  
• Beware of zealotry for a medical intervention.  If question over one of an intervention causes us unease, it may indicate that we are tied more to an idea than to patient care.  For example, I had a visceral response when prompted to re-work my thinking and use IVC ultrasound, in isolation, as a marker of fluid responsiveness.  It was scary to think how I had become so invested in a practice as a medical student.  This may be more difficult for individuals with industry ties or research embedded in one nidus of interest.

3.  Bargaining - We may engage in mental trade-offs with the evidence, using our own experiences/anecdotes or mental frameworks in an effort to trump the data driving the unlearning.  We may utter something along the lines of, "But, I saw Drug X work, in front of my very eyes," despite data demonstrating lack of efficacy.
Action:

• Recognize the cognitive biases we have developed, our heuristics and anecdotes that may cause us to anchor in our learned practice patterns, and attempt to set these aside while we examine the data.  These cognitive short cuts and experiences certainly comprise part of one's clinical gestalt; yet, there may be times in which they act as a crutch.  Once we have a successful, miraculous clinical story of an intervention or diagnosis, we are at risk to become unconsciously attached to the steps that led us to the victorious save.  We have a similarly intense reaction when we experience a negative outcome.  Clinical experience and the best available evidence may work in concert but they also often have a tenuous relationship, filled with bargaining.
• Similarly, recognize the familiar crutches of pathophysiology based answers or surrogate markers/endpoints.  When we dredge up complicated explanations that we were taught in medical school, with several extrapolations to fit the current thinking, this is frequently a marker that our understanding, to that point, was incomplete to begin with (and therefore, should be prime for re-examination).

4.  Depression - We may feel guilty or defeated by this unlearning process and assume that it translates into either a reflection on ourselves or demonstration of the futility of medicine, research, or evidence based medicine.
Action:

• Recall that while we have a seemingly innate desire to intervene, sometimes even apparently harmless interventions carry risks.  
• Reinforce that this is part of the process of practicing medicine, which is a dynamic environment teeming with uncertainty.

5.  Acceptance - Once we acquiesce to the notion that it's necessary to unlearn a practice or thought process in medicine, we are at risk of becoming complacent and failing to unlearn yet again, resulting in a vicious cycle.  Perhaps we should never be fully comfortable with the support for what we do, as that may allow us to become complacent and think that we understand when we don't. We may share in creating a dogma to replace the one we have just unlearned.

Action:  

• Given the changing landscape of medical practice, it's likely wise to regard all of our practices with a skeptical and curious eye. This may allow us the mental flexibility to alter our practice when warranted. 
• FOAM may play a role in allowing one voyeurism into how others are adopting or processing studies so we can identify interventions that may be nearing an inflection point for reversal.
• The use of a filter and "sounding board" for literature does have limitations:
• Selection bias - perhaps only papers in specific areas of interest/popularity are disseminated.  Furthermore, one may only encounter those disseminated by others with similar opinions, serving only to confirm our own biases.  
• Premature adoption - As Ioannidis and Prasad warned, medical interventions undergo reversal frequently so aggressive adoption may expose patients to harms and providers to a bruised ego [1-3].  There's an elusive "sweet spot" between changing/unlearning a practice at a dangerously early time and too late. A previous post addresses the use of FOAM and local "authority" to change practice, and the cautions regarding changing practice discussed therein are also apply here.
• Predigested information can make staying current on literature and ramblings in the medical community easy and practical for busy clinicians but deprives one of the importance of thinking for oneself - it's in this area of work and effort that learning actually takes place.  It's also tempting to simply nod behind others with similar opinions or adopt an expert's view, although this is certainly an issue outside of FOAM as well (e.g. local experts, clinical policies, etc).

References:

1.  Prasad V, Vandross A, Toomey C, et al. A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc. 2013;88(8):790–8.

2.  Ioannidis JP a. How many contemporary medical practices are worse than doing nothing or doing less? Mayo Clin Proc. 2013;88(8):779–81.

3.  Vinay Prasad V, Ioannidis JP.  Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices.  Implement Sci. 2014; 9:1-4.

4.  Ioannidis JP a. Why most published research findings are false. PLoS Med. 2005;2(8):e124. 

5.  Nuzzo R.  Scientific method: Statistical errors Nature 506, 150–152 (13 February 2014) doi:10.1038/506150a 

6.  Rushmer R, Davies H. Unlearning in health care.  Qual Saf Health Care. 2004 December; 13(Suppl 2): ii10–ii15.