Guest Skeptics:Dr. Chris Bond. Chris is a clinical lecturer and emergency physician at the University of Calgary, creator of the SOCMOB blog, dogma basher, and wine/food super geek. Chris appeared on SGEM#86 (Achy Breaky Heart) discussing colchicine as a very effective treatment for acute pericarditis.
Dr. Teresa Chan. Teresa is an Assistant Professor at McMaster University and her research focuses on a number of different areas including: 1) Competency Assessments and Modeling in Residency Education and 2) Social Media Teaching & Learning. She is the co-editor for the Canadian Association of Emergency Physicians (CAEP) Feature Education Innovations (FEI) series.
Dr. Chris Bond and Dr. Teresa Chan
This is going to be the second SGEM-HOP (Hot Off the Press) episode. Usually we are trying to cut the knowledge translation window down from over ten years to less than one year. The SGEM-HOP cuts that KT window down to less than one week. This is done by getting copies of an important Emergency Medicine manuscript prior to publication. Then we do a structured critical review using a method that has been shown to be validated and reliable.
The first SGEM-HOP (SGEM#89) on geriatric falls with Dr. Chris Carpenter was a huge success. One interesting finding from that systematic review was that the inability to cut one’s own toenails had the best negative likelihood ratio for 6-month fall risk. The SGEM bottom line from the fist SGEM-HOP was “We do not have good ED evidence to help us predict accurately or reliably who is at risk of falling. High quality research is need for healthcare providers, funders, and guideline developers to use in deriving screening protocols.”
This second SGEM-HOP is going to be a special one given the holiday season. We used the British Medical Journal (BMJ) holiday edition as inspiration. Each year the BMJ publishes some very entertaining research studies. One of my favourite ones was the Parachute Trial. It was a systematic reviewed looking at whether or not parachutes could prevent death and major trauma related to gravitational challenges?
The SGEM has actually done a few PUB Casts on a couple of BMJ Holiday Edition articles. The first one (SGEM#6) reviewed the study called Orthopedic Surgeons: As Strong as an Ox and almost Twice as Clever? Multi-Centre Prospective Comparative Study. Subramanian et al. BMJ 2011. Their conclusions: “Male orthopedic surgeons have greater intelligence and grip strength than their male anesthetic colleagues, who should find new ways to make fun of their orthopedic friends.”
The other study done as a PUB Cast (SGEM#23) from the BMJ holiday issue was called Pain over Speed Bumps in Diagnosis of Acute Appendicitis: A Diagnostic Accuracy Study. BMJ 2012. Reported pain over a speed bump on the way to the emergency department had a sensitivity of 97% and specificity of 30%. Lack of pain over a speed bump had the best negative likelihood ratio of 0.1 and outperformed migratory pain, nausea/vomiting and rebound tenderness.
So in the parody spirit of the BMJ Holiday edition we give you the holiday edition of the SGEM-HOP. Cutting the KT window down to less than one week.
Case: Jason is a fellow in Cardiology, despite knowing everything about the heart he finds himself struggling with his own. He can easily recite the path of the electrical current from the SA node, through the atria, to the AV node, through the bundle of HIS and Purkinje fibres but he becomes easily lost when required to navigate the path of a relationship. He has recently been on a couple of dates with person of interest but doesn’t know what the next step is.
Background: The systemic assumption that one must be in a relationship in order to be fulfilled is rampant in Western culture but the many hours that young physicians spend in intensive care units, emergency departments and hospital wards often result in missing out on key milestones and skill development that are necessary for successful relationships.
A recent article by Purdy and Johnson in the CMAJ 2014 Holiday Edition raised the concept of evidence-based dating. They created a Johnson-Purdy nomogram similar to the Fagan nomogram. The Fagan nomogram was proposed in 1975 as a graphical tool for estimating the probability a patient has a disease. It requires the physician to estimate the pre-test probability. Then you perform a diagnostic test and draw a line for the post-test probability. The Johnson-Purdy nomogram was a fun way to illustrate an EBM concept and maybe even predict the likelihood of a romantic relationship.
A second article in a series Eve Purdy calls an Evidence-Based Approaches to Life was posted on her Manu et Corde in December. This involved the creation of the Canadian ITAD (Is this a Date) Decision Tool. There are high probability factors and moderate probability factors which raise your ITAD score. There are also factors that will decrease your ITAD score. A total ITAD score >100 predicts you are on a date while an ITAD score of <70 can exclude that you are on a date.
The SGEM has covered two major trials on Early Goal Directed Therapy (EGDT) this year. There was the ProCESS Trial featured on SGEM#69 and the ARISE Trial on SGEM#92. The bottom line from both of these trials was that Invasive EGDT-based sepsis resuscitation was not superior to usual care. The key elements were early recognition of sepsis. liberal IV fluid resuscitation, get a lactate level, empiric antibiotics and admit to an appropriate care setting.
The SGEM was able to get a pre-publication copy of a new protocol called Early Goal Directed Dating (EGDD). This EGDD protocol may support physicians as they navigate the complicated relationship waters and ultimately improve relationship outcomes. This mixed-methods paper first used qualitative methods to develop the algorithm, which was then validated against retrospective recollections of physicians with respect to their current relationship statuses.
Clinical Question: What are the key components/milestones that increase the likelihood of marriage/co-habitation?
Reference: Chan T, Colmers I, Thoma B and Purdy E. Early Goal-Directed Dating in the Treatment of Singledom and Severe Loneliness for Physicians. The New Pun-land Journal of Medicine. In Press…Manu et Corde
Population: Medical students/trainees defined as “single” or “in a successful relationship” of all sexes, races, training programs and sexual orientations were included. Only those with a facebook status “it’s complicated” were excluded from the study.
Intervention: Derivation of the EGDD protocol and then applied in a post hoc retrospective manor
Comparison: Those that were or were not in a relationship
Outcome: Marriage or cohabitation
Author’s Conclusions: “We conclude that the use of goal-directed dating at the earliest stages of a nascent interpersonal romantic relationship may result in more clarity and results with regards to the outcome measures of marriage or cohabitation. A prospective study on this algorithm compared to standard dating practices is needed in order to determine the veracity of our claims.“
Quality Check list for Cohort Studies:
Did the review ask a clearly focused question? Yes
Did the authors use an appropriate method to answer the question? No. The retrospective nature of the study is exceptionally susceptible to recall-bias. Prospective randomized control trial with early stage relationship is needed.
Was the cohort recruited in an acceptable way? Unsure. Is there a better method than getting together casually with friends?
Was the exposure accurately measured to minimize bias? No. The exposure is something similar to EGDD algorithm vs. not. Recall bias!
Was the outcome accurately measured to minimize bias? Yes. Single vs. not.
Have the authors identified all-important confounding factors and were these taken into account in the design? No. If confounding factors were considered, there would be way to many to account for and this is really why a large, randomized control trial is needed.
Was the follow up of subjects complete and long enough? As this was a retrospective study there was no follow. Duration from exposure to outcome measurement is very important in this case however. Ideally a long-term study of person-centered outcomes is needed to ensure happiness over a significant period of time.
What are the results of this study? All those in a successful relationship endorsed the algorithm.
How precise are the results? Unsure. The authors state that they are “confident” but there were no intervals given.
Do you believe the results? Unsure. As always you have to ask yourself “does this make sense”. The algorithm does make sense but it was only retrospectively validated in a bias fashion. The other important consideration is that the “successful” outcome measure, being in a relationship, may be a completely invalid endpoint. They should be measuring happiness, not relationship status.
Can the results be applied to the local population? Yes. It is relevant to the Canadian trainees and young physicians but I would need to see this prospectively validated before it is ready for prime time.
Do the results of this study fit with the available evidence? Yes. Previously published work on this topic including the ITAD Decision Tool and Evidence-based dating: the Johnson Purdy nomogram highlight the need for such algorithms and this piece nicely builds on the growing evidence in this field.
Key Results: The Early Goal Directed Dating (EGDD) algorithm when applied early in a relationship may result in more clarity and results with respect to outcome measures of marriage or co-habitation.
SGEM Commentary: This was a small study but asked a very important question. What are the key components/milestones that increase the likelihood of marriage/co-habitation? However, there were many limits to this study. So many in fact the authors say the limitations were…limitless.
It is important to note that no persons were harmed in the making of this joke article, and hence, the data is completely and utterly the result of the authors’ speculations.
Secondly, a retrospective cohort study is not truly an optimal study design to derive or test such an algorithm.
There were budgetary limitations which precluded a more robust study, but admittedly, a more robust study with a randomized, controlled, prospectively gathered design would require a substantial population, akin to the subject enrollment of the CRASH-2 study (SGEM#80).
Finally, a longitudinal study with more robust follow-up is required to know if, in the end, there is any mortality or morbidity (e.g. heartbreak, separation or divorce) differences between groups, since there is still a possibility that a resultant relationship may only bet temporary, and upon ending might yield further complications down the road.
Comment on author’s conclusion compared to SGEM Conclusion: We agree with the author’s conclusion but we eagerly anticipate the results of the ProCESS EGDD Trial and ARISE EGDD Trial that will compare EGDD to usual dating practices in a head-to-head prospective trial.
What is the Bottom Line?
Need to pick appropriate outcomes – Is relationship status just a surrogate outcome and should the primary outcome really be happiness.
Need to pick appropriate study design – This study design may help you derive and algorithm it may not be sufficient to prove effectiveness of an algorithm.
Need to be skeptical of the evidence – Even parody studies.
Can you give us a Case Resolution: Jason, being up to date on the evidence based dating literature (Johsnon-Purdy nomogram and Canadian ITAD Decision Tool) and decided to apply the EGDD algorithm. He realized that the next best step was to communicate clearly the person of interest about the status of their relationship. Together they decided that they would change their facebook statuses and they have been progressing down the EGDD algorithm since. The authors expect an invite to their wedding.
What do I tell my friend? Don’t stress and have fun! Remember that all the steps are part of the journey.
Keener Kontest:Last keener/gunner winner was Dr. Ben Williams from Nanaimo, British Columbia. He knew the 1918 flu pandemic was also called the Spanish flu.
Listen to this weeks episoe of the SGEM for the keener/gunner question. Send your answer to TheSGEM@gmail.com with keener/gunner in the subject line. The first correct answer will receive a cool skeptical prize.
Remember to be skeptical of anything you learn,
even if you heard it on the Skeptics’ Guide to Emergency Medicine.