Author: psifoundation

A novice physician working in a busy emergency department in the middle of the night may be challenged to diagnose a patient presenting undifferentiated symptoms.

An electronic differential diagnostic (EDS) support system could assist by providing diagnostic hypotheses for the physician to consider – but only if the system is easy to use and fits into the clinician’s workflow.

Dr. Matt Sibbald, associate professor of medicine at McMaster University and cardiologist at Hamilton Health Sciences and Niagara Health System, led PSI Foundation–funded research to examine whether technology and artificial intelligence could improve diagnostic accuracy and when it should be used.

“With the challenge of busy clinical environments, technology might have something to offer to make our lives simpler as clinicians and bring more value and be more effective for patients,” says Dr. Sibbald. “Technology and artificial intelligence could leverage clinicians’ expertise and extend their cognitive capacity. But it needs to be accessible at the point of care without physicians having to modify their workflow.”

EDS support systems have been available for decades and have the potential to reduce diagnostic errors by providing a list of diagnostic hypotheses for the physician to consider. However, the value of the technology has always been limited by the amount of time that physicians needed to spend inputting data into the system – ranging from 20 minutes to even hours per patient.

A platform called Isabel may have greater potential to fit within clinicians’ workflows. After the clinician inputs the patient’s age and just a couple of key symptoms, taking only a minute or two – though Dr. Sibbald notes that this still represents a significant amount of a typical seven-minute emergency department triage visit – the system provides a list of the most common diagnosis differentials.

“It helps with quick decision-making around undifferentiated illness to make sure that you’ve at least thought about the different possibilities,” says Dr. Sibbald. “Some of these hypotheses might not be relevant to the patient in front of you, but that’s for the clinician to dismiss. A system like this is expected to diagnose, but to suggest.”

In 2020, Dr. Sibbald and his team received PSI funding to examine the Isabel EDS system under “sterile” conditions, not a working clinic, as a first step to gauge whether the system could improve the diagnostic process. Clinicians with different levels of experience completed cases through an online platform, with half using EDS early in the process, when only the main patient complaint was available, and half using EDS later, when all patient information including medical history and a physical, was available.

The research team found that the system increased the number of diagnostic hypotheses and the likelihood of the correct diagnosis being included in the list. When Isabel was used early, it generated significantly more diagnostic hypotheses, and when it was used later, the correct diagnosis was included more often in the list of hypotheses. But, ultimately, the researchers found that the system improved the diagnostic process regardless of when it was used and who was using it, though novices benefited the most.

“Electronic differential diagnosis does contribute to physician diagnosis. It adds rigor and length to the differential, and it adds different things for a physician to consider,” says Dr. Sibbald. “We actually saw the most benefit with simplest diagnoses for relatively novice clinicians. We expected that the system would be most helpful with the complex cases, but it helps by pointing to things that you know but haven’t necessarily thought of in the moment.”

Following these positive results, published in BMJ Quality and Safety, Dr. Sibbald and his team have continued to examine how EDS could be used in real-life clinical settings where physicians see patients with undifferentiated illness, such as primary care and the emergency department. They recently published a follow-up study that examined EDS in the context of the emergency room, with a research associate using the technology to simulate how the system could be integrated into the workflow. The results of this study, published in JMIR Human Factors, suggested that the technology needs to be customized to account for the scope and context of the emergency department and the clinician’s experience.

Though there is still a lot of work to be done before EDS is routinely used in clinical settings, Dr. Sibbald says that the potential value of these systems in reducing diagnostic errors is worth the effort. And funding from PSI has been key to the work they have done so far.

“It’s important for PSI to have a broad mandate and scope and to support this type of research that might not be top of mind on the needs spectrum but is still vital for our health care system to grow and adapt,” says Dr. Sibbald. “We can’t keep doing things the same way we’ve been doing them. There’s so much to challenge and to change, and this field can be a key part of that change management. But it needs to be driven by scholarship, research and understanding.”

As a volunteer at a sexual assault crisis centre before starting medical school, Alice Cavanagh would occasionally accompany people who had experienced sexual violence to access emergency health care. While health care professionals’ roles include the important and difficult tasks of collecting samples and evidence, their interactions with the survivor were very different from hers as a volunteer trained primarily to listen and be supportive.

“I became interested in what physicians are actually learning in the course of their professional training about intimate partner violence and sexual violence, and how that shapes their practice,” says Cavanagh. “There is research that quantifies how much education Canadian medical students get on intimate partner violence, but I was really interested in looking at the impact of that education. How are physicians experiencing that training and what are they taking from it?”

When Cavanagh started the MD/PhD program at McMaster University a short time later, she was able to examine these questions, receiving a PSI Research Trainee Award to support her research. With supervision from Dr. Meredith Vanstone and mentorship from Dr. Harriet MacMillan, she led research on how physicians learn about intimate partner violence (IPV) and how that affects the support they provide to patients, and recently defended her dissertation.

In the first part of the study, Cavanagh examined policy and training materials for physicians related to IPV. She then collaborated with the RISE project, a study funded by the Public Health Agency of Canada examining the family violence learning needs and preferences of Canadian social workers and physicians, interviewing physicians and residents across Canada from five medical specialties (emergency medicine, family medicine, obstetrics and gynecology, psychiatry and pediatrics) about their IPV education and the support they provide to patients. She also interviewed health and social service providers outside of medicine about their perceptions of the IPV training that physicians receive.

Physicians often feel unprepared to support people experiencing violence

Cavanagh’s analysis of physician’s training materials found that IPV has become increasingly medicalized, where it is often viewed solely as a health issue, instead of a structural issue with many facets, including poverty, racism, ablism and other forms of oppression. She also found that physicians are taught to identify patients experiencing IPV, provide them with support, and direct them to resources.

At the same time, physicians and residents revealed during the interviews that, while they understood IPV is important to their patients’ health, they largely felt unprepared to support their patients. However, they also spoke about how much they valued experiential learning, which Cavanagh says may offer opportunities to collaborate with IPV experts in other fields to learn directly from patients and other IPV experts.

Interviews with experts outside of medicine confirmed that physicians need to understand IPV and be prepared to support their patients. But they also highlighted that physicians need to be more aware of power dynamics in intimate partner violence, both in terms of the power dynamics between the person who is enacting violence and the person experiencing violence, but also the power that physicians hold in society to make a difference for individual patients and in dismantling the structures that uphold violence.

“It’s not just about understanding, it’s also about engaging with power to move from knowledge to action,” says Cavanagh. “This is a problem that can’t only be addressed by the health care system. By creating opportunities for health care providers to learn about IPV as an issue that is complex and connected to lots of different facets of people’s lives, my hope is health care providers will have opportunities to engage with the type of collective action that is critical to address complex, structural issues like IPV.”

PSI support was instrumental to kickstarting research career

With her dissertation complete and one more year of medical school remaining, Cavanagh is looking forward to continuing research that will improve health policy.

“My goal for my career is to be able to use my clinical work to look at questions about policy and health and to be able to use my research skill set to answer and think through those questions,” she says. “I really believe in the value of clinician-scientists, including those who work outside traditional bench-to-bedside research, and funding from PSI was really instrumental to me in being able to do my work and kickstart my career.”

Cavanagh says the PSI Research Trainee Award provided important financial support during her studies, and PSI meetings gave her important opportunities to connect and collaborate with other researchers.

“In very practical ways, being a part of the community has been really helpful to me in finding and developing new opportunities to grow, which is so important at this stage of my career,” she says.

Cavanagh hopes that the results from her research will help to inform medical education about IPV, particularly in developing opportunities to collaborate with experts from other fields and fostering physicians’ connections with community resources and services to support people experiencing IPV. With more than one quarter of women worldwide having experienced violence, she emphasizes that this issue affects people from all communities, including physicians.

“Violence and structural oppression are pervasive and touch every corner of our lives,” she says. “In health care, if we can have more sensitive conversations about these issues that acknowledge that this isn’t an issue that only affects ‘other’ people, that it affects everyone, I think that we can come toward creating safer places for both patients and providers.”

Over the past several years, and particularly during the COVID-19 pandemic, opioid use disorder has been taking a significant toll on Canadians. According to the Public Health Agency of Canada, between January 2016 and December 2021, more than 29,000 people in Canada died from apparent opioid toxicity, and more than 30,000 hospitalizations were related to opioids.

As evidence has grown in recent years about the risk of opioid use, health care providers are being more careful and deliberate in prescribing opioids to reduce the risk that patients will become long-term opioid users. But this has been a particular challenge in orthopedic surgery.

Research has found that orthopedic surgeons prescribe more opioids than any other surgical specialty. Most patients receive an opioid prescription after surgery, often for more than they need.

“Recovery from these surgeries can be very painful, and as surgeons, there’s a fear that you’re sending patients home with not enough pain control and that they may end up in a pain crisis,” says Dr. Aaron Gazendam, an orthopedic surgery resident at McMaster University. “There’s also been a lack of high-quality research to prove that we can manage this pain without a lot of opioids.”

While working on a Master of Science in Health Research Methodology at McMaster during his residency, he co-led a clinical trial to examine the effectiveness of an opioid-sparing post-operative pain protocol following arthroscopic shoulder and knee surgery.

“Previous research has shown that there is a pretty strong correlation with that initial opioid prescription and the proportion of people who go on to develop chronic use,” says Dr. Gazendam. “We wanted to do an impactful study, and we felt that the results could be implemented after the study to support patients beyond those enrolled in trial.”

In 2021, Dr. Gazendam received a PSI Resident Research Grant to support the Non-Opioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) randomized controlled trial.

The research team, which included orthopedic surgeons and residents, enrolled 200 patients from three clinical sites in Canada who were undergoing outpatient shoulder or knee arthroscopic surgery. The patients were randomly assigned to one of two groups: the control group received the same prescriptions for opioids that they would typically receive outside of a trial, while the experimental, or “opioid-sparing,” group received a prescription for non-steroidal anti-inflammatories (NSAIDs) and acetaminophen, a “rescue prescription” for a small number of opioid pills they could fill if needed, and education about the risks of opioid medications.

At two and six weeks after the surgeries, the research team asked the patients how many opioid pills they used, how much pain they had, and how satisfied they were with their pain control.

They found that patients in the opioid-sparing group were prescribed and consumed significantly fewer opioids than the control group, yet patient-reported pain and patient satisfaction with pain control were not significantly different between the two groups. Importantly, only two people in the opioid-sparing group needed a refill on their opioid prescription, demonstrating that the opioid-sparing protocol was an effective way to manage pain.

“We included patients who were having major surgeries like ACL reconstruction and rotator cuff repairs, so we were in uncharted territory and unsure of how many refills we were going to get during the study,” says Dr. Gazendam. “Leaving patients without access to adequate pain control is a major concern for surgeons, so the fact that only a couple of people needed to refill their opioid prescription was a pleasant surprise.”

The research team now plans to publish the results and work with orthopedic and arthroscopy associations to develop guidelines and position statements that provide evidence-based information about pain management.

As Dr. Gazendam finishes his residency, he plans to specialize in orthopedic oncology and continue studying opioid use in oncology patients, who have very different medication needs and opioid use.

“The question for this project came directly out of our clinical experiences with patients. Being able to investigate questions that come up clinically that have little or no evidence is very rewarding,” says Dr. Gazendam. “The funding from PSI for the NO PAin trial has given me the opportunity to do meaningful and hopefully impactful research that I wouldn’t have had the opportunity to do otherwise.”