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Alan Katz |
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This blog has been created to provide ongoing information about papers of interest to the Family Medicine research community. As these papers come to my attention we will be posting the links to them on this blog. Hopefully this will provide a mechanism for us to share current papers of interest. My posts will be focused on a number of topic areas. Once a year we will archive them under topic headings to keep the website material manageable For assistance with accessing e-journals from the U of M Library, please follow this link: http://umanitoba.ca/libraries/help/elibrary.html
http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673613617274.pdf
Seems odd to circulate a book review, even more so seeing that I have not yet read the book! But this review raises many questions that we as academic family doctors should be thinking about. I have long been a fan of the concept of Reflexivity or what Donald Schon called the Reflective Practitioner. Reflexivity is reflecting, or thinking critically, carefully, honestly and openly, about the clinical experience and process. It is important for us to reflect about our practices, customs and habits as clinicians (and teachers). This process has been codified to some extent in the practice of quality improvement, but that process is limiting. Sanghavi has used this book review to reflect on the strengths and weaknesses of the practice of cardiology in the US over the last 3 decades, mainly in commenting on the book’s content. While it is relatively simple to measure the decrease in mortality due to cardiac disease over the period and use this as starting point as the book under review does, this task is much more challenging for family practice. We have been talking about Primary Care Renewal for over 10 years now, and can point to significant changes in how care is delivered in some practices but I am not sure this applies to the discipline in general and more importantly I am not sure we know what the impact of those changes is on patient wellbeing. We should all reflect on how our patients benefit from our care and how this has changed over time. August 13, 2013 The attached 2 papers tell a sad story of how the public (and the profession to some extent too) is being manipulated. We have seen the growth of a number of new conditions seemingly only discovered after drug treatment was developed (Restless leg syndrome, overactive bladder, Low T to name a few). These papers remind us that the mandate of the pharmaceutical industry is to make money for shareholders, not necessarily to improve the health of our patients. Alan Promoting “LowT” - A Medical Writer’s Perspective Low “T” as in “Template” - How to Sell Disease March 2013 Keep Coming Sarah Wakeman, MD
They shuffle and saunter Strut and stagger Through my open door Week after week.
They banter and bargain Beg and bellow Make promises and deals Tell stories, most true.
They lay bare Their deepest wounds Like the abscesses I sometimes drain.
I return their calls Make more time Write letters to lawyers Challenge deceit.
I held one man’s hand “People are scared of me” Salty sorrow coursed Over tattooed teardrops.
I return handshakes and hugs Say to him, to them I will be here Keep coming.
Published in the Journal of General Internal Medicine 28(2):330 Published online July 13, 2012
October 11, 2012 The Problem of Diagnosis BMJ. British medical journal [0959-8146] Heath Adapting Clinical Guidelines to Take Account of Multimorbidity BMJ. British medical journal [0959-8146] Guthrie yr: 2012 vol: 345 iss: pg: e6341 - e6341 One of the things that makes our work as family physicians challenging (and rewarding) is the fact that we treat people and not disease! There are two articles in the BMJ this week that highlight the challenges of doing this. Inona Heath is a family doc (president of the Royal College of GPs) who has published many outstanding and thoughtful articles about our work. Her paper is interesting and instructive. The second paper on multimorbidity and CPGs is even more instructive. Many of us have long been weary of CPGs due to their many shortcomings. This paper highlights one of those shortcomings. For many of us this is just a reminder of something we "know" and live every day. For teachers this should become a sentinel paper for all residents and medical students to read. Alan
July 26, 2012 The information age has led to the need for new skills, namely knowing where to find a resource rather than having multiple books and expecting people to store the knowledge in their brains. Librarians have gone from Dewy system experts to information management experts. We expect academics to know how to search for current information with the multiple tools available. There is an increasing awareness however, that as the amount information available at our fingertips (literally) grows, finding the right answer also becomes more challenging. Hence the development of inventories of online resources. These include databases that include critically appraised literature, guidelines or other really useful tools. The family med resource page on the library site is really useful! (http://libguides.lib.umanitoba.ca/content.php?pid=231300&sid=1979529) I have also become increasingly impressed with the number of useful online modules that we can access to update our skills. I anticipate that our new scholarly activity curriculum will rely heavily on online modules and tools. One such tool that I recently came across is from the CIHR. The CIHR has a mammoth website that is very difficult to navigate so I intend establishing a short inventory of useful links to specific tools on the CIHR website that will be on our research page. The first is about evaluation. Because we are clinicians and educators primarily but often want to exploit these roles for research this resource is very helpful. http://www.cihr-irsc.gc.ca/e/45336.html I encourage you to spend a few minutes exploring this link.
June 20, 2012 The article attached (above) is an interesting reflection. There is much wisdom and I was particularly struck by the comment about experience and its value. This dovetails well with the rather long (but very interesting) article Teresa circulated yesterday about coaching. http://www.newyorker.com/reporting/2011/10/03/111003fa_fact_gawande?currentPage=all April 3, 2012 Chemo-prophylaxis for Cancer: are we there yet? My interest in primary prevention is pretty much focused on the behavioral aspects of disease prevention. There is much we can do to prevent cancer, CVS and so much more by looking after the Big Five: diet, exercise, smoking, alcohol and stress. We are increasingly encouraged, mainly by big Pharma, to use medications prophylactically. Statins for primary prevention is a key example but there are others like “treatment” of pre-diabetes, and use of Tamoxifen for chemoprophylaxis for prevention of breast cancer. The reality is that when we prescribe drugs to healthy people ie for prevention, the risk-benefit analysis is very different from when we use some of those same drugs to treat conditions known to have harmful effects. ASA has been used for the chemo-prophylaxis of MI and CVA for some time with variable evidence to support this practice. Now there is fairly good evidence of the beneficial effects of ASA in cancer prevention. The attached study is well done. It is not a single RCT but a meta-analysis. The number to treat though is still very high. So what are we to do? Should we be advising our patients to take ASA for the dual benefits of CVS and cancer prevention? Before taking that route I would suggest that we still need to look after the Big Five. Once we’ve tamed them there may be case for ASA. Those more aggressive with chemo-prophylaxis may differ in opinion by I do want to remind you that our primary responsibility as physicians is to do no harm. For those of you celebrating Easter have a Happy Easter, for those celebrating Passover, have a Happy Passover and take the time to reflect on how you can increase your own freedom or that of others. Alan March 7, 2012 Dabigatran Association With Higher Risk of Acute Coronary Events: Meta-analysis of Noninferiority Randomized Controlled Trials (pdf)
Are you an early adopter of new medications? Do you feel that your patients deserve the opportunity to use new promising medications as soon as they are approved? Once again we have evidence that may cause you to temper that enthusiasm! The last 10 years has been one of ups and downs for the pharmaceutical industry. Block buster drugs like Viagra and Atorvastatin have changed the fortunes of major manufacturers and the lives of patients dramatically while other drugs like Vioxx have not done quite so well! The reality is that our drug approval system has faults and there is no simple fix. Regulators walk a fine line between requiring too much evidence of the safety of new drugs thus keeping them off the market while they could be doing much good, and letting potentially harmful drugs be used with detrimental effects on patients. In Canada we have a new system to try to identify previously unknown harmful effects of drugs by using our extensive administrative data holdings. This new CIHR initiative combines epidemiologists across the country in a virtual network to explore the post marketing impact of drugs on a population basis. It is called CNODES: Canadian Network for Observational Drug Effect Studies. We have a local group at MCHP which is part of this network. In the meantime the study above raises serious questions about Dabigatran. While the risk of MI is small in both groups, the relative risk of MI is 30% higher in the Dabigatran group. (Dabigatran, 237 of 20 000 [1.19%] vs control, 83 of 10 514 [0.79%]; OR(M-H), 1.33) This is consistent across the controls and uses of Dabigatran. So what do about a drug that is intended to prevent morbidity (and does) but causes other morbidity with the major benefit of less monitoring…
December 22, 2011 A wonderful video on you tube by Dr. Mike Evans—link below. This family doc has really got it right! http://www.youtube.com/watch?v=aUaInS6HIGo May we all experience this season as one of joy, love peace and happiness. Alan
October 20, 2011 Respiratory tract infections are common. This paper takes a very practical approach to the management of these patients. It is rare that I see residents using pulse oximetry even though it is useful as suggested here. The WRHA has a checklist for indications for admission to hospital for patients with pneumonia which would be a useful tool to use in conjunction with this paper. Investigation of "non-responding" presumed lower respiratory tract infection in primary care BMJ 2011 (pdf) August 4, 2011 I suspect many of you, like me, are wondering about the utility of personalized medicine and when or if this concept will really ever impact upon primary care practice. I learned about slow and fast acetylators and resultant impact on the side effects of treatment for TB during medical school 30 years ago. Nothing of consequence since then! Despite all the hype about the genome project there is little to help us in treating our patients. For some time we have heard that we are on the cusp of these significant breakthroughs!
I thus read the BMJ editorial with considerable interest: http://www.bmj.com.proxy1.lib.umanitoba.ca/content/343/bmj.d4697.full.pdf In contrast, the latest CHEP guidelines are purely RCT based! Yes this is what Evidence Based Medicine would seem to support but in reality I found the BMJ editorial’s explanation for the choices for combination therapy much more plausible and easily applied than the CHEP discussion of this issue! Alan
July 29, 2011 The value of a good editorial: So the question is what is a good editorial? For now I think the answer is a subjective one. If the discussion adds relevant information to your understanding of the evidence, then I think the editorial is useful. If the editorial “parrots” the findings of the paper published in the journal and adds no relevant context then it is not useful. I found the attached editorial very useful and think it provides direct evidence based guidance to family practice. Intensive Glucose Control BMJ 2011 (pdf) Alan July 28, 2011 INRs and Acetaminophen: http://plus.mcmaster.ca/EvidenceUpdates/NewArticles.aspx?Page=1&ArticleID=40966#Data Evidence Updates is a great service that comes to my in box! There is little doubt that Acetaminophen is safer than NSAIDs for pain control in most patients. We often underestimate the negative effects of NSAIDs particularly in the elderly. The finding that all NSAIDs ( not just COX 2 inhibitors where this was first described – remember Viox!) increase the risk of MI was certainly surprising to me. Now we need to be aware of the potential impact of acetaminophen on INR level when we have patients on Coumadin. This is certainly more challenging than other drug interactions with Coumadin because most people who take acetaminophen take it sporadically so when we identify this interaction it seems wise to make any Coumadin adjustments with caution or the patient’s INR level will drop again when the acetaminophen is stopped! Alan June 29, 2011 The main point that this paper makes may be fairly basic to some of us but is a nice discussion of an important approach and the paper may be a good resource for discussion with incoming residents!
Principles of Conservative Prescribing (pdf) May 12, 2011 Getting Evidence into Practice: Tackling inequality by implementing high quality research (pdf) I am not sure why the attached paper grabbed my attention in this week’s BMJ! The title does address the issue of knowledge translation which is, I believe, particularly relevant to Family Practice where we cover such a broad range of issues. This results in the need to actively seek out ways of keeping current, but it is the inequality piece that I think we tend to neglect. Some in our department work with northern communities as part of their normal daily activities. These communities are surely the victims of much of the brunt of the inequity in our system. Most of us ply our clinical trade in the comforts of communities where our patients are resource rich if not personally privileged. A recent report from the Manitoba Centre for Health Policy highlighted some of the inequalities in the health of Manitobans as well as tracking the trends in health inequity: Health Inequities in Manitoba: Is the Socioeconomic Gap in Health Widening or Narrowing Over Time? As family doctors we pride ourselves in being a community based discipline that addresses the needs of our patients and the communities in which they live. After all we know that the health of our patients is dependent on their social environment so our holistic approach leads us to include this social environment in our assessment of our patient’s health. I wander however if we can’t do more to advocate for improved housing, nutrition (supporting breastfeeding for example) and other issues to address some of the many inequities that plague the health of Manitobans. April 25, 2011 I subscribe to the regular EvidenceUpdates by email as a way of keeping up to date. Some of the papers featured are of use to me while others are not. What is important is that these papers have been filtered through a critical appraisal process that makes them a little more useful. You may notice that 7 of the 10 papers featured this week are systematic reviews or meta-analyses. Why am I commenting on this other than the obvious fact that this is a higher level of evidence than RCTs? Last week I attended the Centre for Healthcare Innovation Conference in Winnipeg. The focus of the conference was on optimizing knowledge use as a way of focusing on innovation. Two of the keynote speakers are international knowledge use experts and they both emphasized the need to focus on knowledge synthesis. This appears to be the new frontier of evidence based practice. So they suggested we read only systematic reviews and meta-analyses almost exclusively! RCTs are so often proven wrong when they are replicated that we need more than one RCT to change behaviour! Knowledge synthesis includes systematic reviews but is a broader concept that involves other forms of synthesizing and summarizing the latest evidence. It is an evolving field that we will be hearing about lots over the next few years. Dear Dr. Katz: We thought you might enjoy reviewing the most interesting articles for the past month, based on the frequency with which subscribers viewed these in detail. The top 10 appear below. Brian Haynes MD, Editor, EvidenceUpdates
EvidenceUpdates c/o March 31, 2011 http://www.bmj.com/content/342/bmj.d1199.full.pdf The above paper is a sophisticated meta analysis of the drug treatment of generalized anxiety disorder. It is limited to the drugs available in the UK but is interesting in that we are so heavily influenced by the “flavor of the month” when it comes to the use of these types of drugs. There are so few comparative studies so we often rely on expert opinion which can be influenced by a variety of invalid considerations! Here we have an analysis which provides an objective valid comparison between the drugs included – many of which we use daily. March 11, 2011 Here is a useful paper from the CMAJ that highlights an important drug interaction. Azithromycin seems to be the macrolide of choice to avoid the interaction with Calcium channel blockers. http://www.ncbi.nlm.nih.gov/pubmed/21242274?dopt=Abstract February 7, 2011 As somebody who regularly does pushups I found this one interesting!
A while ago I started getting headaches during my most strenuous exercises. I was advised to pay attention to my breathing and instantly the headaches resolved! The lesson is that breathing appropriately is a critical component of any exercise regimen. Pushups should not involve a valsalva nor should any other aerobic exercise. This example is unlikely to present in any of our exam rooms but the preventive advice is useful to all patients that we encourage to exercise regularly (ie almost every patient we see!!! Valsalva Retinopathy (pdf) January 5, 2011 Our experience with advanced access scheduling has raised questions that some of us have discussed (e.g. the effect on continuity of care) There are many other questions that arise too. This paper is a simple chart audit of ONE practice! It seems to have been a resident project! It seems to me that we could do something similar with different research questions quite easily! Any takers? http://www.cfp.ca/cgi/reprint/57/1/e21 January 19, 2011 Whatever our attitudes to EMRs we all hope that they will help us provide more effective patient care. This is not a given. The two studies below look at the use of decision support within the EMR. This is not just the use of an EMR but an enhanced use with specific reminders. While the results for both are positive they are still very disappointing! Despite the intervention, only 25% of patients received appropriate care with regard to NSAID prescribing! So while the improvement was significant, the end result is still quite poor. There may be reasons for this (like being burned by COX-2’s in the past) but we need to be actively looking for ways to ensure that our EMR makes a significant difference to our quality of care. http://www.annfammed.org/cgi/content/full/9/1/12 http://www.annfammed.org/cgi/content/full/9/1/22
January 11, 2011 Thanks to Teresa for finding this paper for our quarterly journal club. As only a few of us were there I thought it would be useful to share and invite you to discuss this with your residents. I think a discussion of this paper with our residents would be very instructive. The attached paper can be opened with Adobe. The ethical professional as endangered person: blog notes on doctor -patient relationships January 4, 2011 As we move into the realm of the EMR there is room for excitement, anticipation, and of course for some anxiety and doubt. While EMRs have considerable potential to help us improve our patient care and teaching, they also challenge us to adapt our practice to best take advantage of this potential. The attached blog from the NY Times was forwarded by a research colleague from the CPCSSN project. I suspect your responses will be similar to mine (Why was this patient scheduled for surgery anyway?) but I found it did stimulate me to reflect on our imminent entry into the world of EMRs! Happy New Year. http://well.blogs.nytimes.com/2010/12/30/the-doctor-vs-the-computer/
December 13, 2010 This week Marc-Andre Gagnon delivered the attached presentation at Academic Day for the residents. While some of the slides will not make good sense without having heard the presentation, there is a very disturbing message that is clearly presented. Most of us will not be surprised that industry sponsors most of the RCTs conducted and that there is publication bias with positive trials more likely to be published. Where the story gets really concerning is the extent to which the practice of ghost writing has influenced the academic literature. Having a professional writer ensure that the results of an important study are presented clearly sounds like a good idea. Planning multiple publications in advance with the intent of flooding the literature with a single message subverts the process. Journal editors appear to be the victims of a campaign that puts the integrity of the academic literature in serious jeopardy. December 3, 2010 This week I am highlighting a “clinical” study. I have included the “” because this is really a modeling study where sophisticated modeling allows us to compare different treatment options based on what we do know from other studies. Because this is really the best and most definitive study supporting active surveillance for early prostate cancer it is a further indication that PSA screening is not justified by the evidence. http://jama.ama-assn.org/content/304/21/2373.full.pdf+html
November 25, 2010 This editorial provides a neat short summary of the “Medical Home” concept that is the major thrust of much of the US primary care reform. Manitoba Health is looking at a version of this concept and I think many of the principles would be very valid to use as benchmarks for our teaching clinics. Aileen Clarke and Alan B. Cohen Bringing it all back home: can Europeans learn from recent moves toward the medical home in US primary health care reform? Eur J Public Health 2010 20: 613-614; doi:10.1093/eurpub/ckq146.
http://eurpub.oxfordjournals.org/cgi/content/full/20/6/613?etoc
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