Educator Pushes Evidence-Based Approach

Dr. Daniel D. Dressler has devoted the last several years to teaching medical students and residents to think critically about the medical literature and to embrace practicing in an evidence-based world. Dr. Dressler, who was the founding director of the hospital medicine program at Emory University Hospital in Atlanta, currently serves as the university’s hospital medicine associate division director for education and oversees more than 120 hospitalists and 20 midlevel providers.

He directs the department of medicine’s evidence-based medicine curriculum and founded the evidence-based rapid fire track at the Society of Hospital Medicine’s annual meeting.

In an interview, he shared his thoughts on the gaps in available evidence and the pitfalls of practicing based on anecdote.

QUESTION: Where are the gaps in evidence that impact hospitalist practice?

Dr. Dressler: Most clinical conditions have at least some evidence-based literature. Where practicing evidence-based medicine becomes more challenging is in remembering to do everything that is involved in evidence-based practice on a consistent basis, every time we see that kind of patient.

We all have limited memories and limited ability to do multiple tasks at once. So probably the biggest challenge with practicing in an evidence-based fashion is ensuring there are systems or structures in place to allow hospitalists to do those things. That’s why you see core measures around certain conditions to make sure that the evidence-based practice is happening.

The other piece where there are gaps in evidence has more to do with systems, such as transitions of care or the discharge process. What is the best way to discharge a patient to ensure they get the best follow-up care or the most efficient and effective care as they transition from place to place within the hospital? Those are areas where there are definitely gaps, though we’ve been gaining more data recently.

QUESTION: How do you incorporate evidence-based medicine into medical student and resident training?

Dr. Dressler: One of the main goals for trainees is to design well-structured clinical questions and be able to utilize available databases and literature to find the relevant information that’s available to answer those questions. Also, can they interpret that literature in a reasonable and efficient fashion? When I was learning about evidence-based medicine during my training in the late 1990s, it was more about, could we find a piece of literature and interpret it? Now there’s also a significant need to incorporate efficiency. The data suggests that if it takes you more than 2 to 3 minutes to find an answer to your question, you’re just going to stop looking.

QUESTION: Does technology make finding those answers easier?

Dr. Dressler: It is the classic double-edged sword. In some ways it is better because you have so much information at your fingertips. The other side is that resources that come to the top of search lists based on popularity aren’t necessarily the best available evidence to answer your clinical question.

QUESTION: Evidence-based medicine was once derided as cookbook medicine. How have attitudes changed over the years?

Dr. Dressler: Students and trainees are usually very open to the concept of evidence-based medicine because they don’t necessarily have any other preconceived notion of it. I understand that there are some individuals who have a perception of evidence-based medicine as "cookbook medicine."

However, evidence-based medicine is practiced not only using the randomized trials, but also incorporating any of the best available evidence, interpreting that evidence, and using it in conjunction with medical expertise, as well as patient preferences. Occasionally clinicians put too much emphasis on their own expertise. If a physician says, "The last five patients I saw with heart failure didn’t do well with a beta-blocker and I’m going to stop prescribing beta-blockers to patients with heart failure," that’s a misapplication of evidence-based medicine.

Practicing evidence-based medicine means accepting that in a clinical practice you can’t necessarily distinguish between a 2% or 3% or 5% difference in an outcome with different interventions. But those are real differences. Physicians should not be practicing based on anecdote or their experiences with the last two or three or five patients they saw. Instead, when there is robust, high-quality evidence to guide practice, physicians should utilize that randomized-controlled trial data or meta-analysis data, or even cohort or case control data, to guide and influence their daily practice for the betterment of the patients they treat.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

Dr. Daniel D. Dressler has devoted the last several years to teaching medical students and residents to think critically about the medical literature and to embrace practicing in an evidence-based world. Dr. Dressler, who was the founding director of the hospital medicine program at Emory University Hospital in Atlanta, currently serves as the university’s hospital medicine associate division director for education and oversees more than 120 hospitalists and 20 midlevel providers.

He directs the department of medicine’s evidence-based medicine curriculum and founded the evidence-based rapid fire track at the Society of Hospital Medicine’s annual meeting.

In an interview, he shared his thoughts on the gaps in available evidence and the pitfalls of practicing based on anecdote.

QUESTION: Where are the gaps in evidence that impact hospitalist practice?

Dr. Dressler: Most clinical conditions have at least some evidence-based literature. Where practicing evidence-based medicine becomes more challenging is in remembering to do everything that is involved in evidence-based practice on a consistent basis, every time we see that kind of patient.

We all have limited memories and limited ability to do multiple tasks at once. So probably the biggest challenge with practicing in an evidence-based fashion is ensuring there are systems or structures in place to allow hospitalists to do those things. That’s why you see core measures around certain conditions to make sure that the evidence-based practice is happening.

The other piece where there are gaps in evidence has more to do with systems, such as transitions of care or the discharge process. What is the best way to discharge a patient to ensure they get the best follow-up care or the most efficient and effective care as they transition from place to place within the hospital? Those are areas where there are definitely gaps, though we’ve been gaining more data recently.

QUESTION: How do you incorporate evidence-based medicine into medical student and resident training?

Dr. Dressler: One of the main goals for trainees is to design well-structured clinical questions and be able to utilize available databases and literature to find the relevant information that’s available to answer those questions. Also, can they interpret that literature in a reasonable and efficient fashion? When I was learning about evidence-based medicine during my training in the late 1990s, it was more about, could we find a piece of literature and interpret it? Now there’s also a significant need to incorporate efficiency. The data suggests that if it takes you more than 2 to 3 minutes to find an answer to your question, you’re just going to stop looking.

QUESTION: Does technology make finding those answers easier?

Dr. Dressler: It is the classic double-edged sword. In some ways it is better because you have so much information at your fingertips. The other side is that resources that come to the top of search lists based on popularity aren’t necessarily the best available evidence to answer your clinical question.

QUESTION: Evidence-based medicine was once derided as cookbook medicine. How have attitudes changed over the years?

Dr. Dressler: Students and trainees are usually very open to the concept of evidence-based medicine because they don’t necessarily have any other preconceived notion of it. I understand that there are some individuals who have a perception of evidence-based medicine as "cookbook medicine."

However, evidence-based medicine is practiced not only using the randomized trials, but also incorporating any of the best available evidence, interpreting that evidence, and using it in conjunction with medical expertise, as well as patient preferences. Occasionally clinicians put too much emphasis on their own expertise. If a physician says, "The last five patients I saw with heart failure didn’t do well with a beta-blocker and I’m going to stop prescribing beta-blockers to patients with heart failure," that’s a misapplication of evidence-based medicine.

Practicing evidence-based medicine means accepting that in a clinical practice you can’t necessarily distinguish between a 2% or 3% or 5% difference in an outcome with different interventions. But those are real differences. Physicians should not be practicing based on anecdote or their experiences with the last two or three or five patients they saw. Instead, when there is robust, high-quality evidence to guide practice, physicians should utilize that randomized-controlled trial data or meta-analysis data, or even cohort or case control data, to guide and influence their daily practice for the betterment of the patients they treat.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

Dr. Daniel D. Dressler has devoted the last several years to teaching medical students and residents to think critically about the medical literature and to embrace practicing in an evidence-based world. Dr. Dressler, who was the founding director of the hospital medicine program at Emory University Hospital in Atlanta, currently serves as the university’s hospital medicine associate division director for education and oversees more than 120 hospitalists and 20 midlevel providers.

He directs the department of medicine’s evidence-based medicine curriculum and founded the evidence-based rapid fire track at the Society of Hospital Medicine’s annual meeting.

In an interview, he shared his thoughts on the gaps in available evidence and the pitfalls of practicing based on anecdote.

QUESTION: Where are the gaps in evidence that impact hospitalist practice?

Dr. Dressler: Most clinical conditions have at least some evidence-based literature. Where practicing evidence-based medicine becomes more challenging is in remembering to do everything that is involved in evidence-based practice on a consistent basis, every time we see that kind of patient.

We all have limited memories and limited ability to do multiple tasks at once. So probably the biggest challenge with practicing in an evidence-based fashion is ensuring there are systems or structures in place to allow hospitalists to do those things. That’s why you see core measures around certain conditions to make sure that the evidence-based practice is happening.

The other piece where there are gaps in evidence has more to do with systems, such as transitions of care or the discharge process. What is the best way to discharge a patient to ensure they get the best follow-up care or the most efficient and effective care as they transition from place to place within the hospital? Those are areas where there are definitely gaps, though we’ve been gaining more data recently.

QUESTION: How do you incorporate evidence-based medicine into medical student and resident training?

Dr. Dressler: One of the main goals for trainees is to design well-structured clinical questions and be able to utilize available databases and literature to find the relevant information that’s available to answer those questions. Also, can they interpret that literature in a reasonable and efficient fashion? When I was learning about evidence-based medicine during my training in the late 1990s, it was more about, could we find a piece of literature and interpret it? Now there’s also a significant need to incorporate efficiency. The data suggests that if it takes you more than 2 to 3 minutes to find an answer to your question, you’re just going to stop looking.

QUESTION: Does technology make finding those answers easier?

Dr. Dressler: It is the classic double-edged sword. In some ways it is better because you have so much information at your fingertips. The other side is that resources that come to the top of search lists based on popularity aren’t necessarily the best available evidence to answer your clinical question.

QUESTION: Evidence-based medicine was once derided as cookbook medicine. How have attitudes changed over the years?

Dr. Dressler: Students and trainees are usually very open to the concept of evidence-based medicine because they don’t necessarily have any other preconceived notion of it. I understand that there are some individuals who have a perception of evidence-based medicine as "cookbook medicine."

However, evidence-based medicine is practiced not only using the randomized trials, but also incorporating any of the best available evidence, interpreting that evidence, and using it in conjunction with medical expertise, as well as patient preferences. Occasionally clinicians put too much emphasis on their own expertise. If a physician says, "The last five patients I saw with heart failure didn’t do well with a beta-blocker and I’m going to stop prescribing beta-blockers to patients with heart failure," that’s a misapplication of evidence-based medicine.

Practicing evidence-based medicine means accepting that in a clinical practice you can’t necessarily distinguish between a 2% or 3% or 5% difference in an outcome with different interventions. But those are real differences. Physicians should not be practicing based on anecdote or their experiences with the last two or three or five patients they saw. Instead, when there is robust, high-quality evidence to guide practice, physicians should utilize that randomized-controlled trial data or meta-analysis data, or even cohort or case control data, to guide and influence their daily practice for the betterment of the patients they treat.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.