Monday, 24 December 2012

Choosing your Battles: My Christmas Pearl of 2012

This blog post isn't about EBM or getting my hate on about antiquated dogma; it is about a useful pearl that I think can benefit all of my like-minded, avant-garde, #FOAMed friends out there.  In particular, this is a piece of advice that the "young whippersnapper" types like myself should pay attention to.  

Last week while at Tintinalli Rounds with one of my preceptors, we covered tons of material and talked EBM galore.  It was a nerd alert to the extreme.  While we were ranting about how "ridiculous" it is to give gravol to pediatric patients with gastro, and that ondansetron is the evidence based pediatric panacea, we paused for a serious discussion.  As residents soon to enter practice, he gave us this advice.

"Choose your battles"

Having only graduated from residency a few years ago, this preceptor moved from a highly respected pediatric EM fellowship program to a pediatric EM department in its relative infancy.  Upon arrival, he did what most of us would do in the same situation.  He wanted change.  And he didn't want a bit of change, he wanted a revolution.  There was room for improvement everywhere, with everything.  

However, he quickly realized that enthusiasm only goes so far, and knowledge translation can be a bitch.

Rather than revolutionize a new department and effectively ostracize himself in the process, he chose the battles that he wanted to fight.  Every time he saw something in need of change, he asked himself, "is this a battle I want to fight?"  

Ondansetron for pediatric gastroenteritis was a battle he wanted to fight, and there were a couple of others as well.  By limiting himself to a few battles, he could effectively stimulate change, while keeping his new colleagues from beating him senseless.
(Oh fine, I keep mentioning the peds gastro thing so head over to theNNT for a summary of this if you're interested.) 

He also made the point that while some of us are up to date and evidence based, that knowledge will never supplant the 20 years of experience that our older colleagues have.  Rules and scores allow junior physicians to "catch up faster", effectively giving us some of the gestalt that thousands of hours of ER medicine have traditionally provided.  So despite all of your book knowledge, respect your seniors/colleagues.
Another form of choosing your battles is what to do as learners desiring to challenge the status quo.

Here's a twitter conversation I saw today

The context here is that PPIs are not the miracle UGIB treatment that we once thought, and that Lauren, a FOAM loving medical student, tried unsuccessfully to convince someone (I'm guessing an attending) of this.  

This is another form of choosing our battles.  As junior learners/staff, we need to diplomatically approach these topics, and be selective as to how often we question the methods of our seniors.  Nobody likes the learner (or colleague for that matter) who contradicts everything.  I know I have probably been that annoying resident in the past, and thus ask myself "is this really worth it" before choosing a battle.  Furthermore, if circumstances (eg. busy shift, non receptive preceptor) indicate I am about to run into a stone wall, sometimes it's better to just "abort mission" and try again at a better time/place.

For what it's worth, I think Lauren picked a great battle here, and her follow-up tweet to this is impressively mature. This is an excellent example of the attitude FOAM advocates should have, so take note.

To summarize, being young and enthusiastic about medical education, EBM and FOAM is awesome.  But regardless of your medical profession (EMT, nurse, resident, etc.), if you are keen and on the FOAM bandwagon, you will be saying some crazy sounding things.  If you are in a position to effect change, fantastic, but this is another situation where less may be more, and choosing your battles wisely is a lesson for us all.

It's been Christmas Day for 30 minutes now, so put in the Die Hard (or whatever your favorite Christmas movie is), and do not stand on the corner minding your own business. Bruce Willis was just minding his own business at Nakatomi Plaza and look what happened.

With that, I wish you all Happy Holidays (whatever you may celebrate) and a great 2013. 



  1. A fantastic, well-articulated, much needed pearl to close out 2012! Thanks for putting this out there! One of the ways I've found helpful in engendering these conversations without turning them into battles (which would be dangerous/inappropriate at my stage in the game) is to work it into my presentation casually. Ex "So while one may want to also tack on a PPI, particularly the admitting GI doc, the studies behind a recent Cochran review doesn't support that this affects morbidity or mortality so I have planned to hold off on this." This puts into the attending's brain that I have critically thought about the patient's plan in the context of the local environment and body of literature. It may mean that they say, "well, I think you should still start them on a PPI IV" but it gives everyone pause and some food for thought (or the next GI bleeder/whathaveyou) and I may learn something from their experience (which I don't have yet)...all without creating a defensive or argumentative environment. A little trick of the trade that I employ!

  2. Great Post, and recommendation. Also remember that there is power in numbers - if each learner chooses one hill to 'die on', the power to effect change can be multiplied. Learn the evidence and arguments from #FOAMed 'seniors' and use that to encourage change in those more recalcitrant.

  3. Both great comments. The mental imagery of a bunch of medical students and residents dying on these hills is pretty hilarious.
    I actually had this PPI situation myself on a shift last night, and asked if the GI staff still wanted a PPI started. Yup!