EDUCATIONAL SOUNDBITES: Conference Series on Clinical Practice Variations

1. EDUCATIONAL SOUNDBITES: Conference Series on Clinical Practice Variations Michele L. Dorfsman, MD Allan B. Wolfson, MD Department of Emergency Medicine University of Pittsburgh School of Medicine UPMC

2. Background: • Individual variations in clinical practice exist in training programs, even within the same hospital or group • Trainees trying to develop their own practice style can find this variation frustrating or confusing • Faculty members may not even know how much clinical practice variation exists until these issues are brought up for discussion

3. Objectives: • Address individual variations in clinical practice by initiating a conference series to provide a forum for discussion • Provide an open environment for discussion of controversial issues in clinical emergency medicine • Promote discussion of these issues among all physician groups, both faculty, and trainees

4. Design • Residents surveyed to identify the clinical topics • Series of topics chosen for discussion at monthly conference series (2 topics per 1 hour session) • Prior to conference, faculty were surveyed via email or survey monkey regarding their clinical management of a topic • Results of survey presented at conference attended by residents and faculty

5. Clinical Practice Variations Conference

6. Topics Chosen Since Initiation of Program

7. Sample Questions: • Do you always order an ethanol level on patients that have been drinking alcohol? • If not, how do you decide which patients to order it on? • Do you order vitamins for your alcoholic patients that present intoxicated? If so, via which route?

8. Sample Answers • Only in the chronic alcoholic type patients who might be deficient in these vitamins, and then only if they can't take the folate/thiamine/MVI by mouth (difference is pennies vs. hundreds of dollars for banana bag).  I don't give to younger patients who were just out "partying."

9. Sample Answers • I don’t give them IV. If the pt is an alcoholic, I order PO MVI, thiamine, and some food. • I’ll administer IV vitamins if I suspect chronic alcoholism and nutritional issues, with delirium or stigmata. Otherwise oral or no therapy is fine. • If patient systemically ill, emaciated, or being admitted for reason other than EtOH .

10. Sample Answers • Not IV. No evidence for benefit.  If I am concerned about their vitamins I give a PO multivitamin, thiamine and folate when they are awake. • No, I don’t order it. It’s not useful as far as I am aware.

12. Results/Discussion • Residents found conferences extremely helpful in understanding why the practice variations occur • Discussion allowed the residents to weigh the pros and cons of each style of management

13. Results/Discussion • Residents could decide whether the reasoning behind decisions was appropriate based on the discussion • Discussion helpful in allowing attendees to develop a plan when next presented with the clinical issue

14. Results/Discussion • Conference series initiated so much interest that the faculty surveyed asked for the results of the survey and for their own additional conference series which we then initiated • Promoted more discussion on controversial management topics at our program

15. Final Remarks • A clinical practice variation conference series is a unique way to address the confusion that can occur among residents dealing with differences in practice patterns at a training program • Developing a conference series like this requires little money or technology and can be highly productive and improve teaching and discussion at a training program