Slawson and Shaughnessy have developed an innovative and extremely useful approach to information mastery. Central to it is the concept of POEMs and DOEs. The term POEM stands for "Patient Oriented Evidence that Matters", and refers to the kind of article that:
An example of a POEM is a randomized controlled trial that demonstrates that not patching corneal abrasions leads to less pain and faster healing than patching. Why? Let's consider each element. First, corneal abrasion is a problem encountered fairly often by primary care physicians. Second, the article considers pain, healing rate, and complications as the primary outcomes. Clearly, these are outcomes that we and our patients care about. Third, since the traditional practice has been to patch corneal abrasions, this is a "practice-changer".
DOE stands for "Disease-Oriented Evidence". DOEs are all too common in the medical literature, and they are often brought to our attention by pharmaceutical representatives eager to change our practice. However, this kind of evidence is often misleading and generally should be considered premature. For example, early studies of the drug finasteride showed promise, based on the effect on the urinary flow rate. Many patients were put on the drug, at great cost. However, further randomized trials showed that symptom scores did not improve any more than placebo. What do your patients care about - whether their urinary flow rate improved, or whether they are sleeping through the night? When POEMs exist, forget the DOEs.
The following table divides POEMs and DOE into "common" and "uncommon" categories. Common conditiosn are those encountered at least every two weeks in the typical primary care physician's office, while uncommon conditions are those encountered less often:
|
|
POEM |
DOE |
|
Common |
Read these! |
Dangerous |
|
Uncommon |
Read if you have time. |
Worthless |
A third kind of article fills the medical literature: POE's. These studies use patient-oriented outcomes, but the findings don't have the potential to change practice. They confirm what we already do and, while important, are not a priority for our reading.
As a physician caring for patients, you have an obligation to provide the best possible care. You also have a moral obligation to stay up to date. Since time is limited, your efforts should focus on identifying, validating, and applying common POEMs to practice. Actually, focusing your work on POEMs frees you from reading the majority of the medical literature, since over 97% of it is DOEs and other material. This figure comes from a six month survey of 90 journals, which identified 8047 articles and only 213 POEMs (2.6%). This figure includes both common POEMs (encountered at least once every 2 weeks) and uncommon POEMs (encountered less often than every 2 weeks, but at least once over a six month period).
What about all those DOEs? First, ignore the rare DOEs about "zebra" conditions that occur so rarely that a typical primary physician may encounter them only once or twice in a career, if at all. When you have such a case, you can always look it up! Common DOEs, because they do not use patient-oriented outcomes, should not change practice. The medical literature is full of examples where preliminary data were promising, or intermediate results looked good, but disappointing when real patients and real outcomes were measured. Have the confidence to reject these findings as premature. Even "obvious" intermediate outcomes such as blood pressure or cholesterol can be misleading. For example, there has never been a randomized, controlled trial which demonstrated that calcium channel blockers reduce cardiovascular or all cause mortality. Now, some case-control studies suggest that there may even be harm. In fact, among diabetic hypertensives, two randomized trials have now demonstrated increased mortality for calcium channel blockers compared with ACE inhibitors. Similarly, while some anti-hyperlipidemics reduce cardiovascular mortality, they raise all-cause mortality. I don't know about your patients, but mine don't care which category their mortality was in, they just want to avoid it!