SGEM Xtra: EBM and the Changingman

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Date: July 20th, 2020

Guest Skeptic: Professor Simon Carley is Creator, Webmaster, owner and Editor in Chief of the St. Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. Dr. Carley is even verified on twitter as @EMManchester.

Reference: Carley et al. Evidence-based medicine and COVID-19: what to believe and when to change. BMJ_EMJ July 2020

This is an SGEM Xtra episode. It was great to have one of the giants of the FOAMed world back on the SGEM. The last time Dr. Carely was on was on SGEM#148. The bottom line from that episode on skin glue for peripheral intravenous lines was:

“Skin glue does appear to decrease the failure rate of IVs in patients admitted to hospital from the ED at 48 hours. We do not know if this is a good idea for all ED patients and we do not know the true effect size, but for high stakes cannulas that we really want to stay in this intervention should be considered.” 

This SGEM Xtra is based on a wonderful article by Simon Carley, Daniel Horner, Rick Body, and Kevin Mackway-Jones published in the BMJ-Emergency Medicine Journal. The article was titled: Evidence-based medicine and COVID-19: what to believe and when to change.

Simon and I discussed the what inspired him to write this article. It was great that it started with a definition of evidence-based medicine (EBM). They used the one proposed by Dr. David Sackett in 1996: “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”

We gave a shout out to our friends Dr. Justin Morgenstern (First10EM) and Dr. Casey Parker (Broome Doc) on their recent podcast called EBM 2.0 with guest Dr. Senthi.

It is important to remember the literature is just one of three pillars of EBM. There are many problems and limitations with medical research. This includes the dreaded p-value (dichotomization), biases (something that systematically moves us away from the “truth“), and the replication crisis. However, the other two pillars of EBM are equally as important. That includes the clinician’s judgment and the patient’s values and preferences.

The first section of the article was about knowledge translation (KT) during the COVID19 pandemic. Listeners know the the SGEM is trying to cut the KT window down from over 10 years to less than one year using the power of social media. There is a study that quantify the KT gap being 17 years for 14% of high-quality, clinically relevant information to reach the patient (Morris, Wooding and Grant JRSM 2011).

We then went on to talk about the precipitous decisions that are being made during COVID19 and give some examples. This is not a unique situation to a pandemic. There is something called intervention bias. This is the desire by the “medical community to intervene, whether it is with drugs, diagnostic tests, non-invasive procedures, or surgeries, when not intervening would be a reasonable alternative.”

The concept of intervention bias reminds me of one of my favourite ideas I learned from the Legend of EM, Dr. Jerry Hoffman, “don’t just do something, stand there”. There is a great fantastic article on this idea by Keijzers et al 2018.

Many of us have been asked many questions during the pandemic. Some probably have been asked “what would you want if you got COVID19” or “what’s the harm in trying” something to treat this terrible new infectious deadly disease?

We talked about some of these questions and Simon listed some of the potential harms of just trying without good evidence including: distraction, false hope, suboptimal use of resources, misunderstanding of patient trajectory and loss of equipoise. It is also known that harms are systematically underreported in research studies (Saini et al BMJ 2014).

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Four Strategies As A Way Forward

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1. Ensure that every patient with COVID-19 has the opportunity to enter a clinical trial.
2. Ensure that research delivered during a pandemic is of the highest possible quality.
3. Encourage the use of routinely collected, anonymised data to support epidemiological studies.
4. Design studies for deployment in future pandemics and place them in a ‘hibernated state’ such that the research infrastructure is in place prior to requirement.

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I suggested one more strategy to arrive at my favourite number five. The fifth strategy would be (not just during global pandemic) to be skeptical and teach critical thinking skills to other clinicians and the public so they are less likely to be fooled by all the poor arguments and information on social media.

There is a great quote from the website the Logic of Science about this global pandemic and science.

Simon’s final thoughts were from the manuscript.

The SGEM will be back next episode with a critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media (FOAMed). Our ultimate goal is for patients to get the best care, based on the best evidence.

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REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

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Other References: