Comments inserted.
> > 1. What ideas do people have about dealing with the frustration frequently
> > encountered by the realization that for many clinical questions, there are
> > no evidence-based answers? How do you keep the residents from dismissing
> > the whole concept because they cannot yet always find answers in a prompt
> > manner?
It may help to point out that knowledge of a lack of evidence is a far cry
better than a lack of knowledge of the evidence. At the very least, it
may make your residents less dogmatic about their particular approach to
treatment in that area. Hopefully it will also open their eyes to the
extent to which clinical practice in general is based at least to some
degree on tradition and personal experience. This is such a valuable
lesson, which they might not get elsewhere in their medical training.
> >
> > 2. (A question and a request) How valuable do people find the process of
> > structuring the clinical question, per Sackett and others? While it makes
> > sense to me to have the residents think about the question they are asking
> > and focus it, the formal structuring of patient/problem, intervention,
> > comparison, and outcome doesn't always assist in the process of searching
> > for the answer - the search engines do not accept this structure to a
> > query. Thus the request to those of you who are working on the FPIN as
> > well as others - wouldn't it be nice if we had a database that could be
> > searched by structuring and then asking your question in this format, or
> > at least in a way that facilitated the process of moving from the clinical
> > situation to the information needs in a relatively direct way.
> > Thanks in advance for thoughts on these matters. Neil Korsen
Two thoughts on this:
1. It helps me realize that the literature can never fully answer the
question I want to answer, and have to settle for a focused question which
only approximates the one I really want to answer.
2. I am better informed if the clinical situation or my planned therapy
deviates from the specifics of the question which has been asked and
answered.
For example, if I want to know:
What is the best steroid regimen for treating croup?
I have to ask a series of questions, two of which might be:
In children with a clinical diagnosis of croup, does dexamethasone 0.3
mg/kg decrease croup scores/decrease the need for follow-up
visits/decrease admissions as well as dexamethasone 0.6 mg/kg?
In children with a clinical diagnosis of croup, does prednisone 2 mg/kg/d
for three days decrease croup scores/decrease the need for follow-up
visits/decrease admissions as well as a single dose of dexamethasone 0.3
mg/kg?
If I am lucky enough to get a good answer to these focused questions, I
still haven't necessarily optimally answered the first question. I think
this again illustrates that medical decision-making is based on limited
information. Awareness of the ways in which it is limited is nevetheless
powerful. I might have a good reason to choose prednisone or
methylprednisolone for a particular patient, for example. If I know that
the standard for treating croup with dexamethasone 0.6 mg/kg came about
primarily because this is the regimen that was studied, rather than
because various regimens were tested and this is the only one found to
work, then I might not mind deviating from the standard in rare
circumstances where a different steroid regimen makes more sense.
Julie
Julie Brown, MD
Pediatric Emergency Medicine Fellow, box CH-04
Children's Hospital and Regional Medical Center
Seattle, WA 98105
e-mail: [log in to unmask]
fax: 206 527 3892
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