Zerhouni Challenge, anyone?

[Hard24Get]

Just as I am becoming more obsessed with all things EM, seems like the forum is dying down. Does anyone want to discuss the fundamental hypothesis of EM research?

If so, please read the Zerhouni challenge, also on the SAEM webpage.

Do you agree with the proposed hypothesis of EM research, that "Rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves patient outcomes"?

If not, how would you change it?

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[ERMudPhud]

I read that article when it first came out and it left me mostly annoyed. Other fields of medicine are not generally required to state their "fundamental hypothesis" What is the fundamental hypothesis of rheumatology research or urology or ID or whatever. I think you have to judge a research proposal or program based on its own merits and not on its relevance to a field wide fundamental hypothesis. Part of the appeal of medical research is that its a very very big house and even subdivisions like surgery or EM are huge. Sure, the NIH and other funding entities have priorities but requiring every project to fit under a field wide umbrella results in an umbrella so wide it is meaningless or research program so narrow it misses out on too much

Of course I'm getting out of research and never really did EM research so why should I care

 

[Janders]

If we have to state a hypothesis, it sounds like a good one to me. I think the given examples of domestic violence and disaster medicine DO fit into that (very) general statement. Can we think of any good EM research that couldn't fit into that hypothesis (For those not reading the full article, "that hypothesis" is "rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves patient outcomes.").

I think there might be some sociology/demographic/social-science research that occurs in EDs that doesn't exactly fit that hypothesis, but I can't give a good example off the top of my head. I'll try to remember one and post it.

 

[Hard24Get]

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[Hard24Get]

I read that article when it first came out and it left me mostly annoyed. Other fields of medicine are not generally required to state their "fundamental hypothesis" What is the fundamental hypothesis of rheumatology research or urology or ID or whatever. I think you have to judge a research proposal or program based on its own merits and not on its relevance to a field wide fundamental hypothesis. Part of the appeal of medical research is that its a very very big house and even subdivisions like surgery or EM are huge. Sure, the NIH and other funding entities have priorities but requiring every project to fit under a field wide umbrella results in an umbrella so wide it is meaningless or research program so narrow it misses out on too much

It is true that other fields don't have to justify as much as we do, but it is true that EM is unique in that it involves several fields. Since the meeting was to discuss EM research, it was reasonable, I think, for Zerhouni to ask why it should be prioritized rather than just letting the subspecialists do all the work. Other fields would arguably be better adapted to research the only diseases they think about each day. For EM, we can claim diagnostics, timing, and early treatment modalities as our area of expertise rather than
infiltrative cardiomyopathy or primary biliary cirrhosis.

I think for the basic science research i would add something with regard to the initial molecular events of a disease lending themselves to powerful therapeutic intervention. An example of this is investigation of acute HIV infection. If we can stop the virus from seeding, this likely to be more effective than later therapies. I would argue that this falls within the realm of EM as well.

Of course I'm getting out of research and never really did EM research so why should I care

I'm sure you are joking. You know why you should care, don't you? Even if you never go back to research, there are too few basic science-trained EPs for you to wash your hands of the issue. Even though you were on your way out when I joined SDN, you really helped me at a critical decision point and now I couldn't be happier or more committed to academic EM. I hope you will continue to discuss aspects of EM research as well as encourage those interested in EM research to pursue it.

 

[docB]

Sure, the NIH and other funding entities have priorities but requiring every project to fit under a field wide umbrella results in an umbrella so wide it is meaningless or research program so narrow it misses out on too much

I agree. A lot of this stuff sounds like the rambling of the type of people who read and write "Mission Statements."

It is true that other fields don't have to justify as much as we do, but it is true that EM is unique in that it involves several fields.

I was at a conference once where Nate Kupperman and Peter Rosen got into an argument about this exact thing. This was 2003 and the discussion was about EM research needing buy in from other fields, in that case pediatrics. Rosen's ultimate summation on the subject was a loud, definitive "F--k 'em!" He want on to clarify that as a specialty we have been around long enough that we need to start treating ourselves like grown ups and doing our own research for our own needs in the ED. Just some color for the discussion.

 

[AmoryBlaine]

I guess that's sort of an interesting hypothesis, I just have to agree with some of the others who have questioned the necessity/impact of it.

Although I'm lowly (M4) I tend to be very unimpressed with the majority of EM research. Even in the big 2 journals (AEM, Annals) it seems like many of the original articles are small studies that can't always be easily translated to practice. There always seems to be something about "Charateristics of patients who leave w/o being seen."

"Doctor Blaine, this patient in triage meets 4/5 criteria of the Gonnaleave system, I think we should make them red."

I also think that having a "fundamental hypothesis" is sort of limiting and maybe even a little silly. What is the fundamental hypothesis for IM research? "Making people better is good?" Or surgery? "Cutting people open to make them better is good?"

 

[Hard24Get]

I agree. A lot of this stuff sounds like the rambling of the type of people who read and write "Mission Statements."

I was at a conference once where Nate Kupperman and Peter Rosen got into an argument about this exact thing. This was 2003 and the discussion was about EM research needing buy in from other fields, in that case pediatrics. Rosen's ultimate summation on the subject was a loud, definitive "F--k 'em!" He want on to clarify that as a specialty we have been around long enough that we need to start treating ourselves like grown ups and doing our own research for our own needs in the ED. Just some color for the discussion.

I also think that having a "fundamental hypothesis" is sort of limiting and maybe even a little silly. What is the fundamental hypothesis for IM research? "Making people better is good?" Or surgery? "Cutting people open to make them better is good?"

Well, since the only reason to cater to the NIH is to get funding for an EM research network, perhaps a better question would be do we need one? I am actually on a committee that is supposed to form a conference to address this issue. I think many see an EM network as an opportunity to combine ED patient data and samples from across the nation in order to pull off studies which are more powerful than any one ED alone can do. In order to get that, we would have to sell the NIH on EM research in general. No attempt to sell the NIH on IM or Surgery research is necessary simply because they are not asking for a network. Right now the only real networks in place are at CTSA institutions, with a few scattered state-wide EM networks. I personally think that the acute diseases intrinsic to EM are best studied in the large sample sizes that a network would afford.

Although I'm lowly (M4) I tend to be very unimpressed with the majority of EM research. Even in the big 2 journals (AEM, Annals) it seems like many of the original articles are small studies that can't always be easily translated to practice. There always seems to be something about "Charateristics of patients who leave w/o being seen."

It's true that, as a relatively new specialty, EM research is in its infancy. Some stuff that gets done seems like "out of curiosity" stuff, and I think that's ok. Other stuff is public health oriented, which is key for the ED to do. But we can do critical work that impacts all of medicine. Look at the EGDT studies, the BNP studies, the CT to r/o CAD, the ischemia/reperfusion and hypothermia studies, etc, etc, etc. We do, can, and will conduct excellent research - watch (or even better - participate) and see, my colleague.

 

[roja]

He want on to clarify that as a specialty we have been around long enough that we need to start treating ourselves like grown ups and doing our own research for our own needs in the ED.

*applauds*

I couldn't agree more. It seems as so many EM people seem to feel that justifying themselves, thier practice and thier research is of utmost importance.

We need to *stop* trying to please others and focus on doing research that is relevant to us. We need to focus on making sure that our research is of solid quality ('weak' research abounds all fields, not just EM).

A hypothesis is nice but to me, doesn't realy address what needs to be done: we need more people, doing relevant, quality research in EM.

 

[ERMudPhud]

The point of science is to propose AND TESThypotheses. An untestable hypothesis is merely a statement of faith and becomes religion(or a mission statement). Generally, if we find even one exception to the hypothesis we consider it disproven. A statement like "Rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves patient outcomes" is too broad to be testable in a meaningful way. On the face of it there are plenty of "acute illnesses" in which outcomes cannot be improved no matter how rapidly you diagnose it and intervene. A gun shot wound that transects the brain stem or extensive hydroflouric acid burns/poisoning come immediately to mind. Sure you can bring up the whole field of injury prevention but now you've broadened your hypothesis even more. Why not just say "Taking care of sick people or protecting them from their own self destructive impulses(whilst saving them from having to call their PCP) is a very good thing"

More importantly asking for a field wide hypothesis sends the message that you must first "prove" that hypothesis in order to justify your field(and funding for your field). Should we stop funding all EM research until we "prove" the Neumar hypothesis. In science we never "prove" hypotheses, we "test." If we test them and they are found lacking we consider them disproved and form a new hypothesis. If the NIH requires you to first "prove" or attempt to "prove" that "Rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves patient outcomes" before funding your research they are asking you to fail. All I have to do is dip you in a vat of HF while shooting you in the brainstem to disprove your hypothesis.

If you want to present the same idea as a "Scope of EM research" or "Mission statement for EM research." thats fine. Just don't consider it a testable hypothesis. Rewrite it as "EM research: improving prevention, early diagnosis and treatment of acute decompensation (whilst saving you from having to bother your PCP" and don't try to prove thats a good thing. If its friday night I'm sure the PCP's at least will agree with you.

 

[Hard24Get]

If you want to present the same idea as a "Scope of EM research" or "Mission statement for EM research."

I presume this is what Zerhouni was asking for and was trying to be cute with terminology. BTW, the impoverished NIH IS setting people up to fail these days, or haven't you noticed?

 

[docB]

Zerhouni challenge, also on the SAEM webpage.

Do you agree with the proposed hypothesis of EM research, that "Rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves patient outcomes"?

You know, I've been thinking about this for a few days and I changed my mind a little. To me it seems like academic folly but acadamia is dedicated to these types of discussions. So, for the sake of discussion, I thought we might view this hypothesis in terms of some of the best research in EM and see how it fits or doesn't.

I'll start by suggesting that this hypothesis does not encompass a highly beneficial body of research about using rules to limit resource waste. I'm thinking of studies like the NEXUS rules, Canadian neck rules, Ottowa knee and ankle rules, etc. Those studies do not purport to achieve early intervention or diagnosis (do they?). They are about increasing wise utilization and patient flow through overcrowded EDs. So, agree, disagree, change the hypothesis or DocB you're an idiot?

 

[ERMudPhud]

I'll start by suggesting that this hypothesis does not encompass a highly beneficial body of research about using rules to limit resource waste. I'm thinking of studies like the NEXUS rules, Canadian neck rules, Ottowa knee and ankle rules, etc. Those studies do not purport to achieve early intervention or diagnosis (do they?). They are about increasing wise utilization and patient flow through overcrowded EDs. So, agree, disagree, change the hypothesis or DocB you're an idiot?

Totally agree. Fortunately you just have to change the hypothesis to "Early and Appropriate"

 

[DropkickMurphy]

Rosen's ultimate summation on the subject was a loud, definitive "F--k 'em!"

Yet another reason to respect the man.

I think many see an EM network as an opportunity to combine ED patient data and samples from across the nation in order to pull off studies which are more powerful than any one ED alone can do.

It's an admirable goal, but just like with the National Trauma Data Bank (which I am working with the data from on my injury prevention project) it seems like any attempt to do this normally starts off with some insipid idea and slowly morphs into something usable. From what I was told by one of the administrative people with NTDB, the original impetus behind that was to increase the power of trauma research but it wound up feeding more than just the surgeons' needs. Although there are still shortcomings with that data set but that's a topic for another thread.....

While the Zerhouni idea might be worthy of ridicule for being slightly inane, if it provides the impetus necessary to secure funding that will allow a nation wide EM research network to form, then perhaps we should play along. My great grandmother used to tell me (as a small child) something in German that translates basically to "Sometimes you have to befriend the devil to do the work of the angels." Perhaps that is the challenge here.....to perhaps pay a small price in exchange for a greater reward.

The thing to keep in mind though is that once it is established we (meaning those of you in the positions of sufficient authority to do so and those who stand in the ranks behind you as a legion of sorts) need to bend it, tweak it and hammer it into the form of something more in line with what we really need to advance the field.

A statement like "Rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves patient outcomes" is too broad to be testable in a meaningful way.

Then perhaps the attempt should be made to have several interrelated, yet disparate enough to test hypotheses as our statement if we have to have one at all.

Of course, it's just my 2 cents as a lowly allied health worker......