Medical education is a lifelong learning process.11,12 From a consumers’ perspective, our patients expect, and often believe, that their physicians are keeping their knowledge and skills current.
Most medical boards now require that physicians accumulate a significant number of CME hours to re-new their licenses. Medical specialty boards are now also emphasizing maintenance of certification as a way to establish physicians’ lifelong learning. While often we may not think of professional competency as an ethical requirement, ethical background is founded on being primarily responsible for the welfare of the patient through professional competency, striving to continue to learn, being honest with colleagues and patients, and demonstrating responsibility to society.13 This concept of professional competency as an ethical responsibility was probably best described by Clifford14 in The Ethics of Belief: “It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence.” Of course, the challenge we face is that knowledge continues to grow, our understanding of illnesses we treat continues to evolve, and our hold on “truth” is never complete.
We know that all scientific truths are provisional! What is concerning to both consumers and professionals is that as research and technology rapidly advance, the gap between what should be done in clinical settings and what is actually practiced appears to be widening. This has led to a paradox: we live in times when the treatment of mental disorders has never been more effective, yet many of our patients do not benefit from these hard-achieved scientific advances.
It is well established that there is a gulf between what we know and what we practice. Large gaps exist between best evidence and practice in the implementation of guidelines.15 Failure to follow best evi-dence highlights issues of underuse, overuse, and misuse of drugs16 and has led to widespread interest in the safety of patients.17 These serious and widespread quality problems have occurred “in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care.”16
Literature reviews conducted by RAND had previously identified studies that document quality shortcomings. Large gaps between the care patients should have received and the care they did receive were identified. This was true for preventive, acute, and long-term care across all health care settings and for all age-groups and geographic areas.18 The Institute of Medicine’s major and widely cited reports described this problem as follows: “Between the health care we have and the care we could have lies not just a gap, but a chasm.”17 Understandably, there is an increasing public concern about the lack of access to appropriate treatment, pervasiveness of unsafe practices, wasteful uses of precious competence, and unsatisfactory patient outcomes.
Now, more than ever, we need novel methods to help us rapidly identify, evaluate, consolidate, and distribute new knowledge. This requires tools for real-time analysis and decision support.
We live in an age of information. But how much of this information is useful, and how much of it gets in the way of learning and keeping up? The answer depends on our ability to find a signal in the noise of this information explosion.19
The signal to noise ratio [SNR] is a useful concept in determining what information is relevant. The SNR is a qualitative measure of value received relative to the irrelevant data one must sift through to get to that value. In other words, the task at hand is to find the information and knowledge bases that improve medical decision making and can be effectively applied in current clinical practice. Many efforts continue to be made to narrow the gap between evidence and clinical practice. These efforts have included educational strategies to alter practice behavior and interventions at the organizational and administrative levels.20,21
The Medical Informatics Panel of the Medical School Objectives Project of the Association of American Medical Colleges identified the following 5 major roles played by physicians in the area of medical informatics: lifelong learner, clinician, educator-communicator, researcher, and manager.11
This report further states that to successfully perform as a lifelong learner, a physician must be able to demonstrate competence in many areas, including knowledge of the information resources and tools available to support lifelong learning; ability to retrieve, filter, evaluate, and reconcile information; and attitudes that support the effective use of information technology. While there are many ways to acquire and practice these skills, it is the position of this report that evidence-based medicine provides a coherent approach to do exactly that for patient care.
A “top 25 list” that can help
In future columns, I will illustrate one approach to keeping current with critical findings that are relevant to clinical practice. In an effort to sort and evaluate published research that is ready for clinical use (ie, finding a signal in the noise), I used the following 3-step method to find new information in the previous year that had applicability to clinical decision making and to make a personal judgment as to which information was the most useful:
1. Search select literature published between June 1, 2010, and May 31, 2011.
2. Survey the American Association of Chairs of Departments of Psychiatry, the American Association of Directors of Psychiatric Residency Training, the American Association of Community Psychiatrists, the American Association of Psychiatric Administrators, the North Carolina Psychiatric Association, the Group for Advancement of Psychiatry, and other colleagues with the following question: Among the papers published from June 1, 2010, to May 31, 2011, which ones in your opinion have affected or changed the clinical practice of psychiatry?
3. Look for appraisals in online post-publication reviews, including Faculty of 1000,22 NTK Institute,23 MDLinx Psychiatry,24 and Evidence Updates From the BMJ Evidence Centre,25 and in secondary sources, such as Evidence-Based Mental Health.26
The papers were chosen on the basis of their clinical relevance/applicability—ie, their “clinic readiness.” The order in which the papers appear in the list is arbitrary.
We need to come up with systems with an acceptable SNR to efficiently identify, evaluate, and apply new information. A method that has been used to develop an annual “top 10” list of important, clinically relevant findings that have been presented at regional psychiatric association meetings and that have been well received has been described. While the method relies on evidence-based thinking, there is subjective judgment involved in selecting the “top” of any list, and this is not an argument that the method or the selection is “best.” The list is useful, nonetheless, and it is hoped that it will be improved by sharing.
In my next column, I will present an expanded, “top 25” list.