For more than 99% of the million or so years that humanity
has existed, our only method of sharing information was
the spoken word. When Sumerian moneylenders invented written
record-keeping about 5,000 years ago, they opened vast
new possibilities for the dissemination of knowledge and
humanity has never looked back.
Until now, that is. The Journal
of the American Medical Association (JAMA), frustrated
that their best research is being ignored in actual
practice, has turned back to the oral tradition in an
attempt to get doctors to pay attention. JAMA's
new scheme, called "Author in the Room," invites published
researchers to present their findings to actual practitioners
in monthly conference calls.
The first phone-in took place on
March 23 and presented findings from the Women's Health
Initiative (WHI), which suggested that hormone therapy,
contrary to accepted wisdom, does not help alleviate
urinary incontinence in postmenopausal women, and in
fact makes it worse.
BREAKING
BOUNDARIES
JAMA Editor-in-Chief Dr Catherine DeAngelis explained
the rationale behind "Author in the Room" to the doctors
who phoned in: "We see how often things published in
our journal that make good sense, are well-documented,
absolutely evidence-based medicine, and yet we get other
papers that show it just doesn't seem to be penetrating.
This seemed a superb way to study the problem and find
out what is that gigantic barrier."
The initiative is a joint effort
by JAMA and the Institute for Healthcare Improvement
(IHI). Dr Donald Berwick, IHI's director, also participated
in the phone-in. He said: "Literally decades can pass
between the publication of a paper and its implementation
in practice. We have enormous respect for the problems
that participants have in making changes to practice,
and for the skepticism that they ought to have before
they take action. Through this call hopefully we can
make that bridge."
Their choice of paper for the first
call-in session was intriguing. It was a bold choice,
because it criticizes a standard treatment, and many
callers were indeed quite skeptical about its findings.
On the other hand, the WHI is hardly an ideal exemplar
of a study that failed to influence clinical practice.
It could be argued that no study in the history of medicine
has had such a dramatic influence on practice as did
WHI, which single-handedly knocked the bottom out of
the hormone therapy market.
A
QUESTION OF TIME
The call attracted 184 participants, and lasted one
hour. The second half-hour was devoted to question-and-answer.
That left time for 11 questions total. There's a problem
here, which is that the more people participate, the
less chance each has of posing a question. In fact,
it's a bit like a TV gameshow. Once questions are opened,
everyone must dive for buttons on their telephone keypad.
Dr Norman Barwin, an Ontario gynecologist
who participated, didn't get to ask his question but
praised the idea nonetheless. "It's nice to get that
spontaneity, and a particular benefit is that you get
to hear the concerns of other practitioners. I think
the questions were just as interesting as the answers.
It reminded me of a university lecture, but like a lecture,
it's hit-or-miss whether you get to ask your own question
at the end."
He thought "an excellent solution"
would be a written, web-based, interactive question-and-answer
session. "Then, everybody would get to ask their questions.
And if you wanted to review the information, it would
be easy to find." The written word remains a very good
way of transmitting information.
Dr Margaret Winker, JAMA
deputy editor, said such an idea might be tried in the
future. In the meantime, transcripts could potentially
save readers the trouble of trawling through the full
one-hour audio file (available on IHI's website) to
find the answer to a particular question. "But we're
operating on a fixed grant, and transcripts cost money."
EXPERIMENTS
EVOLVE
"We're open to any new methods," said Dr Winker. "This
is essentially an experiment." And JAMA being
the evidence-based journal that it is, they're naturally
compiling data on the experiment. Participants had to
complete a survey immediately after the conference call,
and will answer followup questions in three months to
see what impact, if any, the teleconference had on their
clinical practice. "Unfortunately I can't reveal the
survey results," said Dr Winker, "as we're planning
to publish it."
Published JAMA articles,
of course, are proprietary information and cost money
to access. Which is an interesting point when one considers
the problem of translating research into practice. Dr
Barwin notes: "It would be essentially pointless to
participate if you hadn't read the article and didn't
have a copy in your lap." The phone-in is free for the
first 200 participants. But if you want to read the
article and don't already have access to JAMA,
you'll have to pay $12US for 24-hour access.
Subscribing is not necessarily
the answer, since there's no way to predict which journals
will carry the articles you want over the coming year.
Those who have free access to a whole range of journals
tend to be specialists and academics — yet it's
family doctors who are on the frontline when it comes
to putting this kind of research into practice.
There's another problem that JAMA
and the IHI might consider. One participant noted that
doctors "don't like to make considerable changes in
their practice based on one study. They like to wait
for confirmation, more time going by, discussion with
colleagues, before going ahead." Academic medicine is
all about getting published, but there are more researchers
than research topics. When researchers revisit a well-trodden
research path, they need to show that they offer something
different. Often this comes down to denigrating the
methodology of previous research. It's no wonder that
physicians tend to be skeptical.
The next "Author in the Room" session
features JAMA's April 6 article "Outcomes in
Hypertensive Black and Nonblack Patients Treated With
Chlorthalidone, Amlodipine, and Lisinopril."
Register at http://www.ihi.org/IHI/Programs/ConferencesAndTraining/Author+in+the+Room.htm?TabId=10
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