Competency 2.2: Understand the clinical relevance of scientific inquiry and demonstrate the ability to evaluate emerging knowledge and research as it applies to diagnosis, treatment, and the prevention of disease.
As I have transitioned from preclinical studies to clinical rotations to preparing for internship, I am gradually learning how to ask focused clinical questions. Clinical questions fill a specific gap in knowledge that can be utilized in decision making for individual patients. Over the past few years, I practiced gathering and reviewing known information to find a known answer about a clinical disease. In contrast, for unresolved clinical problems, I have to learn to evaluate an evolving body of literature to answer a clinical inquiry.
One of my assignments during my AMRCC rotation was to perform a critical appraisal of the literature to answer a clinical question. Endocrinology tends to be a highly data-driven specialty, and so I decided to investigate the literature on treatment pathways for a patient of mine with Grave’s disease. I looked up the guidelines on what we could offer for patients in her condition and copied in all the available studies to support those guidelines. After submitting my assignment, I was surprised to receive feedback that I had summarized the literature but not critically evaluated it. I looked back at my work to see what I had missed. In answering this question, I looked to find the ‘most correct’ answer—the same way I might confirm my answer to a clinical vignette on a board exam. However, the purpose of the assignment was to demonstrate critical appraisal—identifying the strengths, limitations, and biases of a given study. In my eagerness to identify and prove the answer, I missed the point—the answers to our questions are not always clear cut, and we need to be prepared to think critically. Medicine is constantly evolving, and as clinicians we need use critical appraisal to decide how convincingly the emerging literature supports a change in practice.
In my third year of medical school, I decided to engage in clinical research. I had done multiple basic science projects in cardiology and figured that my next step would be to gain clinical experience. I asked Dr. Emani, a cardiologist I had shadowed, if he might have a clinical project I could assist with. He described a clinical question he had in mind to investigate.
The clinical question was straightforward, but nuanced. He hoped to investigate the utility of high-risk PCI in patients with severe heart failure. Since these patients typically have severe comorbidities, they are often excluded from clinical trials. I started the project by performing a literature search of survival in heart failure patients. But as I poured through the literature, I lost sight of the initial question by delving into comparisons of PCI versus surgery. Although the populations were similar, the results weren’t relevant because the patients were healthy enough for surgery. We stepped back and revisited the initial question. I imagined that I was a critically ill patient with systolic heart failure and had to choose between high-risk PCI or medical therapy alone. There was a gap in the literature that left me uncertain which option would prolong my life. When I framed the question with a clinical example, I was able to redirect and focus my literature search. I applied for an IRB and was able to lead an investigation of retrospective outcomes from high-risk PCI. My abstract was recently accepted for a poster presentation at the 2021 American Cardiology Conference.
During my sub-internship in general medicine, my attending frequently asked me to find answers to clinical questions that arose on rounds. For example, he asked me one day to look up what’s known on triple therapy for COPD exacerbation. I had to think beyond the what of currently available therapies, as I would for an exam question. I had to think about why triple therapy might be advantageous and how the available evidence supported this. One of the residents pointed me to Wiki Journal Club to help compare and contrast clinical trials. I believe this skill will be useful during residency, not only for answering questions posed by my attendings, but also to actively compare evidence-based treatment options for individual patients.
I had the opportunity to formally demonstrate these skills by presenting a case report at the OSU Hospital Medicine Symposium. Midway through my sub-internship, we diagnosed a patient with eosinophilic gastroenteritis. The clinical presentation was complicated. We were convinced the patient had Crohn’s disease until his gastrointestinal workup unexpectedly returned with evidence of a rare inflammatory disease. The patient had been suffering for several months with undiagnosed abdominal pain. My attending suggested I write a case report. Having a clinical perspective to pair with the disease presentation, I researched potential clinical pitfalls and strategies to help hospitalists hasten diagnosis. By recognizing the earliest signs and key findings of this disease, we can recognize it early and avoid mis-diagnosis and delayed treatment.
As a future physician, my duty is to provide patients with excellent care founded on evidence-based medicine. Clinical curiosity and ability to critically appraise emerging literature are key to improving medical care. In the future, I hope to use critical thinking skills to inform my clinical practice and lead clinical research projects. I have started incorporating review of the medical literature within my weekly routine. Below are my next steps to reach these goals:
SMART Goals:
- Recognize clinical uncertainty during my future medicine rotations
- Maintain a list of clinical questions that arise during intern year. Return to this list every few months and highlight the questions I cannot find answers to in the literature. Consider starting a clinical research project.
- Ask attendings for input on clinical questions to gain perspective and identify potential clinical research questions.
- Ask my senior residents for tips on how to efficiently search the literature for state of the art literature.
- Read the Scope and 2 NEJM articles each week to build a habit and stay updated on breakthrough studies.