What is Your Strategy to Stay Current with Ever Changing Evidence?

Last week I was too appalled after an experience to write in a nice, polite manner.  Ladies, you are all familiar with the wonderful pelvic exam.  Now, I made a conscious choice to not go to my primary care physician.  I most definitely trust him, but he's one of those guys who is somewhat like an older brother to me.  I just couldn't bring myself to assume the position with someone I tease, joke with, argue with, physically shove around and probably irritate.  So… I asked around and chose to have the exam with an ob-gyn I had never met.  The website looked like most any other and she was younger… it's a simple pelvic exam right?  Mentally, I thought younger might be better.

I would like to think there has been a change in the medical world where evidence is valued and evidence assists in making clinical decisions.  After the experience I had with a younger physician who focuses on a narrow scope of knowledge, I'm not so sure.  So, to narrow the focus of my visit with her down even more – it was simply a visit to screen for cervical cancer and ovarian cancer, right?  Well, things have changed over the years.  As I'm sitting there naked, with just a cheap cotton gown between myself and her, she brings up the traditional aspect of the exam – the Papanicolaou (Pap) test – should be combined with the primary human papillomavirus (HPV) DNA screening.  She stated the HPV screening would probably not be covered by insurance.  Now, I don't let that kind of thing necessarily bother me and instead generally need additional information in order to make my own health decisions.   Sadly, the physician wasn't able to provide me with the sensitivity, specificity or the likelihood ratios of the test.  She also did a really, really poor job of describing the various clinical scenarios with various test results and how the test would assist in determining what might occur due to test results.  She narrowed the value of the HPV screening down to one simple thing – if the HPV was negative, I would need no further screening for 3 years.  Now, maybe it was surprising that I wanted specific evidence on the test… maybe it was surprising that I didn't want to fork out an additional $100 without having a clear rationale about the value that test would have for me personally… maybe she just didn't know the evidence of the test.  I really don't know and… I didn't confront her at the time with my appall  because while sitting on an examination table naked under a cotton gown, staring at a speculum and a pile of oozed lubricant on a gauze pad just didn't feel like the right time to question her lack of knowledge any further.

What about us?  We work with people every day and make clinical decisions all the time.  What do we base our decisions on?  Do we have an attitude that the person has insurance benefits for physical therapy and physical therapy is cheaper and safer than surgery, injections or drugs, so why not have physical therapy intervention?  Do we do our best to make clinical decisions taking into consideration the strength of the evidence for those decisions?  Imagine if… imagine if you could have something at your fingertips to help you remember details.  Something quick and dirty… something where you can pull the information quickly – maybe even right there in front of the patient.  Guess what?  There's an app for that!  Yup… I wish the ob-gyn had something concrete and accurate to assist me in making a decision… physical therapists do!

So, the medical and physical therapy worlds are continually evolving.  How you practice today, better not be how you practice in 10 years!  What strategy do you have in place to assist you in evolving with the world?

~Selena

5 responses to “What is Your Strategy to Stay Current with Ever Changing Evidence?

  1. Carina Lowry says:

    Selena,
    I am chuckling to myself right now, because most of the men who read this probably were just nauseated.
    On the other hand, I was just at my OB 2 weeks ago, and he wanted me to get a new US + blood test that is a new screening test for major developmental defects. It’s the “first trimester screen” and it looks at the cleft along the base of the neck combined with a blood screen like the second trimester quad screen. I was very impressed that he said if the screen was negative that he was 85% certain that there were no defects. But alas, I think that we should also point out that these tests are screening tests with high sensitivity only to rule out conditions and give probabilities that the condition is not present. Positive tests just mean that you have to undergo more testing…..

  2. Deydre says:

    Selena:
    So funny! I was roaring! So true!

  3. Carina Lowry says:

    Hey Selena–
    Just a follow up–I visited my family medicine doctor twice this week. She had this nifty app on her iPhone that showed all the drugs, interactions, classifications, indications, safety during pregnancy, etc and was able to speak to me about Class A vs. B vs. C and the risks of each. I will definitely be going back to see her.
    Just wanted to get your thoughts on using this type of technology and pts perception? I always think that pts appreciate the research behind our decisions, but do you think this may backfire on us? How can we keep from being a cookbook profession?

  4. Congrats on your pregnancy. You’ll have to keep me updated on your experience!
    One of my high school friends is an anesthesiologist and she has apps like that on her phone. The amount of information out there is overwhelming and it isn’t feasible to truly remember everything combined with how often the information changes.
    In my opinion, we should use the resources we have to help us do what it is we do AND do it right the first time. No one debates about using billing software that checks procedural codes with ICD-9 codes to eliminate denials. No one debates documentation software that ensures all the required information for payment in the event of an audit is within the initial evaluation, the encounter note, the progress note or the plan of care.
    I think in the future, some of the app technology on the various diagnostic tests will actually be included within the documentation software and will be pushed at us. I also think at some point in the future, the documentation software used will also have the capability to do some data mining and will be able to push information on the results of treatment intervention of patients just like the one just evaluated. Our profession is probably a long way down the road from technology being used this way because as a whole our profession isn’t valuing this type of information or demanding to have this type of information. Although this is true, I think it is a definite possibility.
    I tend to believe if we focus on building a relationship with the person in front of us and use the technology as a tool to help keep the focus on the patient, the patient is generally going to have positive perceptions. If we choose to let technology be front and center and the “relationship” revolves around the technology, I don’t believe the patient will have a positive perception. The beauty of the technology is it is available to use at any point in time. We don’t have to choose to use it in front of a patient. The patient and the intensity of the “need to know” of the patient could be what determines if we whip an app out.
    I have never appreciated the idea that using evidence = cookbook. If the patient is always kept front and center and the focus of the interaction, there is no cookbook about the interaction. Having a patient centered approach creates balance – it can’t be fully cookbook if the patient’s thoughts, perceptions, beliefs and goals are part of the equation. The evidence should definitely help drive decisions, but the twist lies in the “art” of how well one is able to incorporate it within the treatment intervention so that the patient’s perceptions, beliefs, thoughts and goals converge with the evidence.

  5. Dan Rhon says:

    Great post Selena. I think the app you meant to link here was CORE – Clinical ORthopaedic Exam as that is the one that has all the diagnostic properties for clinical tests we use. The current link points to Mobile OMT which is a manual therapy app.
    CORE Link here: http://itunes.apple.com/us/app/core-clinical-orthopedic-exam/id329470520?mt=8

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