I’m doing this blog to try to show a different way of doing medicine.
I pursued my M.Ed in an attempt to teach better, and ended up thinking differently. Let me be clear. I always felt I was a decent physician, a decent man. But now I know I’m better. I’ve seen my approach to medicine, and to people in general, change. That’s not ego, that’s not hyperbole, that’s not distortion. It’s not an attempt at reducing cognitive dissonance after paying tuition. It’s real. And it’s because of this training.
You see, medicine is a thing. It can come in a bottle. It can be learned from a book. But more than anything, medicine is a verb. You and I do it. “Doing medicine”. That’s what we do at the office, on the ward, in the ER. A verb.
Some of this blog, some of these posts, and pages, are M.Ed retreads. These “retreads” are little papers I wrote during that program, with a bit of a spin to make them “blog-able”, more pertinent for my associates, colleagues, students. I’m doing that for myself, also, to try to keep this alive, in my head and in my heart. And some of this blog is working journal.
I want other physicians, and medical students, to see the change, and the challenge. To see how the process is so completely different. To see how a different approach can help.
As an example, I’m currently doing what I thought was going to be an ex post facto piece on the US Lipid Guidelines, and how the imposition of them has changed my practice. I was going to look at 2 weeks now, and compare them to similar weeks a year ago.
An ex post facto study looks at something that has already happened, sort of an historical look over the shoulder to examine how the rock hitting the still surface raised ripples.
The 2013 US Lipid Guidelines came out in, well, 2013.
This is 2014, in case anyone forgot. I read the guidelines, like many of you, when they came out, with a potful of coffee to get me through the 50 pages. Then I started doing my thing. “Doing medicine.” What we all do. Practise.
Thought I had it cold. I was introducing changes, and spouting off to both colleagues and patients about how it had all changed. Then it occurred to me to do this ex post facto thing.
With a grunt, I went back to the guidelines, as of course I’d have to write a bit of a summary. This “going back” occurred during my initial implementation period. In fact, I’ve already blogged about how I was faced with breaking rules.
During my second round with the guidelines I recognized, with a second grunt, that there were a couple of wrinkles. I wasn’t doing this quite correctly, according to Hoyle as it were. Remember, this is my public journal. This is where I bare my soul, and show you how this training, this perspective changes things, changes how I practise. I’m doing this to practise better. I’m hoping by reading this, you’ll be more aware of what can happen in the human mind.
I use PS Suite EMR. Within there is a risk calculator built on the Framingham risk criteria. Sort of. It also, for example, includes “relative” less than 55 with ASCVD. That’s not in the actual Framingham calculator. It’s sort of an accepted risk factor (actually, in the 2013 guidelines, it’s male relative with ASCVD ≤ 55, or female relative ≤ 65. And this is a non subgroup, additional factor that you look at when considering treatment).
It didn’t fully penetrate my thick gourd, that with the 2013 Guidelines, came completely new equations. That was one of the largest issues! Maybe the biggest! They were not Framingham, and they were not convertible.
I spent quite some time looking for conversion tables. Why? Laziness? I just wanted to use the built in calculator that was already in my system? Was it that? I got all hung up for a while with Imperial (I guess they call them US measurements in the US) measurements, vs SI, thinking I wasn’t converting properly, as I wasn’t getting the same numbers.
I had also completely jumped on the wagon for non fasting lab tests. There is a big push now to do non fasting lipids, at least in Canada. Hey, the patients love it! There’s less of a log jam in the morning at the lab! And, of course, the decisions and theory, and practice around the US Lipid guidelines demand fasting values.
Major gaff. Would I have caught this if I wasn’t trying to at least semi-formally present my “ex post facto” study? I can tell you the answer. I would have continued right along my own little distorted path. Sometimes this “Doing Medicine” is a bit too much of a verb. We run from exam room to exam room. There’s more patients to see than we can cope with. We need to stop and think, to see if we’re on the right path. Writing this stuff down formally is not just a formality. It’s necessary to keep the facts straight, keep you straight, the practising physician.
An action research approach to medicine helps keep you on that right path. Formal quality improvement plans aren’t there to try to satisfy some kind of governmental demand. They help you practise medicine, better. “Doing medicine”, better.
So, now my ex post facto study may be something else. During the next couple of weeks I’ll be introducing the 2013 Lipid Guidelines into my practice, right this time. Or, as right as this GP can figure them. I’ll be carrying my iPhone in my pocket with my handy app, and working out the actual Pooled Cohort Equations. Flipping that rock out there, seeing some ripples.
(Yes, I found an app that had SI units.)
(Did you ever think it funny that the US is stuck on Imperial measures?)