Mini-interview with Dr. Jahan Fahimi

Dr. Jahan Fahimi, MD Assistant Clinical Professor of Emergency Medicine UC San Francisco

Dr. Fahimi will be lecturing at UCSF’s High Risk Emergency Medicine Conference on Friday June 10th on “EM Myths and Controversies: An Evidence-based Approach”.

You have extensive research experience; what is the basis for most myths in EM? What is the most peculiar one you can recall and what is a popular one that still persists?

I think most myths are based in outdated research or dogma that was never evidence based. So much of what we do is based in dogma that is passed down through the generations, or is just an institutional bias. Some of the myths are based in bad research (hormone replacement therapy and cardiovascular risk, for example). These are so pervasive in medicine. As far as EM goes, we are often stuck doing things the way other specialties have been doing them for years. For example, surgery and GI always want NG tubes placed. And there’s a role for NG tubes, but not in every patient. So, EM needs to (and has been) carving out it’s own evidence-based approach to patient management.

What are the barriers that prevent physicians from halting the process of propagating myths?

Physicians can be slow on the uptake when it comes to new evidence. It’s rare that research changes practice immediately. And it probably shouldn’t change practice too quickly. We know that findings in research vs. in practice are quite different. Stated benefits just aren’t there sometimes, especially when management is applied in less-than-ideal circumstances. But when there is good evidence to change behavior, physicians may be too apprehensive to change right away — it’s easier to stick with what has worked in the past.

How do you integrate an evidence based approach with clinical judgment when there might not be studies that have a good answer for a complex patient?

Extrapolation of evidence is one approach, though not ideal. This is the fun part of medicine. You apply some heuristics, try and rely on experience, and hope that it’s getting you close to the right answer.

With many algorithms dominating the care of patients have you found more reliable patient care being implemented? Is there risk of patient harm with too rigidly protocalized care? Do you think there is room for deviation of these algorithms that can still be viewed as doing what reasonable physicians would ordinarily do?

Protocolized medicine is great as it helps standardize practice and hopefully leans on best practices. However, in an attempt to be one-size-fits-all, the protocols may be too general or rely on over-testing. Just because there are protocols, it doesn’t mean they are evidence based. So, I think you need buy-in from clinicians and then there needs to be flexibility in deviating from the protocols. Finally, even when there is evidence for a protocol or clinical decision-rule to guide management, we cannot blindly accept them until there have been impact analyses done to ensure that, in practice, the benefits are similar to what was purported in the ideal research conditions (i.e., derivation and validation phases).

For more on myths in EM and evidence based medicine join us at the HREM Conference. www.highriskem.com

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