JAMA Article Research Articles

Making Healthcare Safe: The Story of the Patient Safety Movement

Making Healthcare Safe: The Story of the Patient Safety Movement

First person profile: Ezekiel "Zeke" Emanuel, MD, PhD: Bioethics pioneer leads multiple efforts to improve US and global health care.

First person profile: Ezekiel "Zeke" Emanuel, MD, PhD: Bioethics pioneer leads multiple efforts to improve US and global health care.

Marijuana: Dangerous for Developing Brain

Back to table of contents Previous article Next article ProfessionalFull AccessMarijuana: Dangerous for Developing BrainMarilyn FenichelMarilyn FenichelSearch for more papers by this authorPublished Online:3 Dec 2019https://doi.org/10.1176/appi.pn.2019.11b28AbstractThe increasing potency of marijuana and misconceptions about its safety were the drivers behind the advisory, directed specifically at adolescents and pregnant women. In August, Surgeon General Jerome M. Adams, M.S., M.P.H., issued an advisory flagging marijuana as a danger to adolescents and pregnant women. The advisory emphasized that the developing brain is particularly vulnerable to the effects of THC (delta-9-tetrahydrocannabinol), the component that induces feelings of euphoria and is responsible for the experience of “getting high.” Mounting evidence shows that for the developing fetus, marijuana use can have adverse effects such as low birthweight; for adolescents, it can result in deficits in attention, memory, decision making, and motivation.The advisory was spurred by increased access to marijuana and concerns about its potency: The THC in cultivated marijuana plants inceased from 4% to 12% between 1995 and 2014. For adolescents, especially those who start using marijuana at a younger age, the higher the THC concentration, the greater the risks are for addiction and other negative outcomes, such as anxiety, agitation, paranoia, and even psychosis, the advisory noted.“The advisory … presents a good entry point for discussions with patients and families about the risks of cannabis on the developing brain.” —Smita Das, M.D., Ph.D., M.P.H.According to Smita Das, M.D., Ph.D., M.P.H., who conducts addiction research at Stanford University and is the medical director of psychiatry at Lyra Health, as well as a member of the APA’s Council on Addiction Psychiatry, there is a need among psychiatrists for guidance on how best to approach the subject of cannabis use with patients. “The advisory … presents a good entry point for discussions with patients and families about the risks of cannabis on the developing brain,” she told Psychiatric News.Staci Gruber, Ph.D., director of the Cognitive and Clinical Neuroimaging Core and Marijuana Investigations for Neuroscientific Discovery at McLean Hospital in Boston and an associate professor of psychiatry at Harvard, agreed. She added that “people are desperate for information, especially since the nation has warmed significantly toward using cannabis for a variety of different problems.” For example, she explained, pregnant women may turn to marijuana in an attempt to reduce symptoms of nausea and vomiting that come with morning sickness. “But using marijuana for this purpose is not without risk because the THC can be passed to the unborn child,” Gruber said.Statistics on marijuana use among pregnant women highlight the cause for concern. According to a survey conducted by Nora Volkow, M.D., director of the National Institute on Drug Abuse, and colleagues, published in June in JAMA, the number of pregnant women who used marijuana monthly rose from 3.4% in 2002 to 7% in 2017. Among women in their first trimester, monthly marijuana use rose from 5.7% in 2002 to 12.1% in 2017. The evidence of growing use of marijuana in this population prompted both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics to issue strong warnings against marijuana use during pregnancy.The number of youth using marijuana is also of concern. The 2017 National Survey on Drug Use and Health found that about 9.2 million young people between the ages of 12 and 15 reported using marijuana within the past month. Equally concerning is that in recent years, adolescents’ perception of harm caused by marijuana has been declining, perhaps because of the growing number of states that have legalized its use for adults. However, marijuana is illegal at both the state and federal levels for young people.“There’s no question that for brains under development, cannabis use has a negative impact, and the effects can show up over time,” said Gruber. “For those under the age of 16 who are chronic, heavy users, the effect on executive functioning can be significant.”The surgeon general’s advisory is the first step of a messaging campaign and programs aimed at prevention. For psychiatrists, the document has particular value. “It gives them evidence at their fingertips to explain the risks of cannabis use,” Das said. “It also may be a starting point for discussing [a patient’s] interest in reducing marijuana use or quitting altogether.”Gruber, too, thinks the document is important. “It’s an unregulated market out there,” she said. “While in many circumstances, medical marijuana may prove to be beneficial, at this point, there are many unknowns. If the marijuana has not been certified by a physician, the best course of action for most people is to just say no.” ■The surgeon general’s advisory is posted here. The JAMA article, “Self-reported Medical and Nonmedical Cannabis Use Among Pregnant Women in the United States,” is posted here. ISSUES NewArchived

Association between conflict of interest and published position on tumor-treating fields for the treatment of glioblastoma

ObjectiveTo investigate a possible association between authors’ financial conflict-of-interest and published position on the clinical application of a medical device utilizing tumor-treating fields (TTF) for the treatment of Glioblastoma. MethodsWe searched Google Scholar for all articles that cite the 2015 JAMA article on TTF in treating glioblastoma. All articles were read in full to identify editorials or review articles that focus on the use of TTF in treating glioblastoma. Selected articles were coded by two investigators as favorable toward the use of TTF, or neutral/ unfavorable. Conflict-of-interest as declared by each author was recorded, and The CMS “Open Payments” Registry was used to independently identify conflict for each listed author of included articles. ResultsThere were 15 articles with 44 independent authors included in our analysis. Of the 15 articles, nine articles were categorized as favorable with 35 authors. Of the 35 authors with favorable views, 77% (26/35) had financial conflict-of-interest with the maker of TTF, compared to 11% (1/9) of authors of neutral articles. Authors of articles with a favorable stance towards TTF were more likely to have received payments from the device manufacturer worth greater than 1 000 dollars than authors of neutral articles (66% vs. 0%, p = 0.001). Among the nine favorable articles, 89% (8/9) had at least one author who had received greater than 1 000 dollars from the device manufacturer. ConclusionOur study shows an association between authors' published stance on the use of tumor-treating fields for the treatment of glioblastoma and financial ties to the manufacturer of this device.

The future of artificial intelligence and interpretative specialization in clinical biochemistry

• A recent article in JAMA by Jha and Topol discusses the potential combined impact of digital images and artificial intelligence (AI) on the future of pathology and radiology

New puzzles for the use of non-invasive ventilation for immunosuppressed patients.

On October 27, 2015, Lemile and colleagues published an article in JAMA entitled "Effect of Noninvasive Ventilation vs. Oxygen Therapy on Mortality among Immunocompromised Patients with Acute Respiratory Failure: A Randomized Clinical Trial", which investigated the effects of non-invasive ventilation (NIV) in 28-day mortality of 374 critically ill immunosuppressed patients. The authors found that among immunosuppressed patients admitted to the intensive care unit (ICU) with hypoxemic acute respiratory failure, early NIV compared with oxygen therapy alone did not reduce 28-day mortality. Furthermore, different from the previous publications, there were no significant differences in ICU-acquired infections, duration of mechanical ventilation, or lengths of ICU or hospital stays. The study power was limited, median oxygen flow used was higher than used before or 9 L/min, NIV settings provided tidal volumes higher than what is considered protective nowadays or from 7 to 10 mL/kg of ideal body weight and the hypoxemic respiratory failure was moderate to severe (median PaO2/FIO2 was around 140), a group prone to failure in noninvasive ventilatory support. Doubts arose regarding the early use of NIV in immunosuppressed critically ill patients with non-hypercapnic hypoxemic respiratory failure that need to be solved in the near future.

Critical care of obese patients during and after spine surgery.

Obesity is one of the most prevalent health problems facing the United States today, with a recent JAMA article published in 2014 estimating the prevalence of one third of all adults in the United States being obese. Also, due to technological advancements, the incidence of spine surgeries is growing. Considering these overall increases in both obesity and the performance of spinal surgeries, it can be inferred that more spinal surgery candidates will be obese. Due to this, certain factors must be taken into consideration when dealing with spine surgeries in the obese. Obesity is closely correlated with additional medical comorbidities, including hypertension, coronary artery disease, congestive heart failure, and diabetes mellitus. The pre-operative evaluation may be more difficult, as a more extensive medical evaluation may be needed. Also, adequate radiographic images can be difficult to obtain due to patient size and equipment limitations. Administering anesthesia becomes more difficult, as does proper patient positioning. Post-operatively, the obese patient is at greater risk for reintubation, difficulty with pain control, wound infection and deep vein thrombosis. However, despite these concerns, appropriate clinical outcomes can still be achieved in the obese spine surgical candidate. Obesity, therefore, is not a contraindication to spine surgery, and appropriate patient selection remains the key to obtaining favorable clinical outcomes.

Point: Introducing Diversity Into a Medical Group: How to Do It and Why

In their JAMA article suitably titled “Everyone’s a Little Biased (Even Physicians),” Cain and Detsky [1] noted that “bias is not a crime, is not necessarily intentional, and is not a sign of lack of integrity; rather, it is a natural phenomenon.” Is it realistic to disregard Cain and Detsky’s hypothesis? Not really because, by denying the pervasive “natural” presence of bias, the individual limits his or her capacity to finally confront the depths of bias and prejudice. We need to own up. So how does the individual routinely cope with his or her own biases? That’s simpleeeither deny them, or excuse them as harmless. However, both excusing and denying get complicated when the individuals gather for the monthly partners’ meeting. There, biases may summate and become overt. For example, in its hiring practices, the group may prefer a male to a female employee. It may prefer an individual trained on the east coast, or west coast, or in the Midwest. A specific cultural or ethnic heritage may be preferred. Age, sexual preference, gender identity, and disability can be problematic. We convince ourselves that these preferences are acceptable because they seem to strengthen group culture and professional services. Meanwhile, the strategic partners applaud the group’s ongoing

Cluster randomized trials: evaluating treatments applied to groups.

Sometimes a new treatment is best introduced to an entire group of patients rather than to individual patients. Examples include when the new approach requires procedures be followed by multiple members of a health care team or when the new technique is applied to the environment of care (eg, a method for cleaning a hospital room before it is known which patient will be assigned the room). This avoids confusion that could occur if all caregivers had to keep track of which patients were being treated the old way and which were being treated the newway. One approach to evaluate the efficacy of such treatments— treatments for which the application typically involves changes at the level of the health care practice, hospital unit, or even health care system—is to conduct a cluster randomized trial. In a cluster randomized trial, study participants are randomized in groups or clusters so that all members within a single group are assigned to either the experimental intervention or the control.1,2 This contrasts with the more familiar randomized clinical trial (RCT) in which randomization occurs at the level of the individual participant, and the treatment assigned to one study participant is essentially independent of the treatment assigned to any other. In a cluster randomized trial, the cluster is the unit randomized, whereas in a traditional RCT, the individual study participant is randomized. In both types of trials, however, the outcomes of interest are recorded for each participant individually. Although there are both theoretical and pragmatic reasons for using cluster randomization in a clinical trial, doing so introduces a fundamental challenge to those analyzing and interpreting the results of the trial: study participants from the same cluster (eg, patients treated within the same medical practice or hospital unit) tend to be more similar to each other than participants from different clusters.2 This nearly universal fact violates a common assumption of most statistical tests, namely, that individual observations are independent of each other. To obtain valid results, a cluster randomized trial must be analyzed using statistical methods that account for the greater similarity between individual participants from the same cluster compared with those from different clusters.2-4 In a recent JAMA article, Curley et al5 reported the results of RESTORE, a cluster randomized clinical trial evaluating a nurseimplemented, goal-directed sedation protocol for children with acute respiratory failure receiving mechanical ventilation in the intensive care setting, comparing this approach with usual care. The trial evaluated the primary hypothesis that the intervention group—patients treated in intensive care units (ICUs) using the goal-directed sedation protocol—would have a shorter duration of mechanical ventilation. Thirty-one pediatric ICUs, the “clusters,” were randomized to either implement the goal-directed sedation protocol or continue their usual care practices. Use of theMethod

The Art and Craft of Writing for Self-Care and Narrative Advocacy: A Workshop in Reflective and Public Writing (P11)

Objectives Describe the nature of suffering and the types of responses to it. Enact principles of mindful practice to enhance participants’ ability to respond effectively to suffering. Palliative care, which promotes compassionate care amid serious illnesses, depends on practitioners’ ability to cultivate attentiveness, self-compassion, resilience, and mindfulness in their interactions with patients, families, and colleagues. AAHPM prioritizes ‘‘identifying opportunities for enhanced self-care and resilience’’ as a key objective for its Annual Assembly sessions. However, few structured opportunities exist for practitioners to develop self-awareness amid the unpredictability and stresses of clinical practice. This workshop will offer an experiential introduction to mindful practiced‘‘momentto-moment purposeful attentiveness to one’s own mental processes during every day work with the goal of practicing with clarity and compassion.’’ The format is based on intensive courses for health professionals, which have resulted in greater resilience, empathy, and psychosocial orientation while reducing burnout. We will introduce principles of mindful practice through formal and informal contemplative practices, narrative and appreciative inquiry exercises, and research on mindful practice training for cliniciansdbuilding on intellectual foundations outlined in two seminal articles in JAMA (Epstein, 1999; Krasner et al., 2009) and Academic Medicine (Beckman et al., 2012). The workshop will address noticing suffering and responding to it, building on themes addressed in prior AAHPM sessions. After discussing principles of mindful practice, we will explore ways clinicians notice and respond to suffering including ‘‘fixing,’’ ‘‘compassionate solidarity,’’ and ‘‘transformation.’’ We will introduce brief secular, contemplative exercises to draw attention to bodily sensations, thoughts, and feelings to promote self-awareness and awareness of one’s environment. A narrative reflective writing exercise will focus on personal clinical experiences related to suffering and ‘‘turning toward suffering’’; participants will take turns telling and listening to each other’s stories using techniques of reflective questioning. Next we will address ways in which mindfulness can be applied to clinical practice. Finally there will be discussion about how to grow and sustain mindful practice in participants’ own work settings.

Responding to Suffering: An Introduction to Mindful Practice and Mindful Communication (P10)

•Describe the nature of suffering and the types of responses to it.•Enact principles of mindful practice to enhance participants’ ability to respond effectively to suffering. Palliative care, which promotes compassionate care amid serious illnesses, depends on practitioners’ ability to cultivate attentiveness, self-compassion, resilience, and mindfulness in their interactions with patients, families, and colleagues. AAHPM prioritizes “identifying opportunities for enhanced self-care and resilience” as a key objective for its Annual Assembly sessions. However, few structured opportunities exist for practitioners to develop self-awareness amid the unpredictability and stresses of clinical practice. This workshop will offer an experiential introduction to mindful practice—“moment-to-moment purposeful attentiveness to one’s own mental processes during every day work with the goal of practicing with clarity and compassion.” The format is based on intensive courses for health professionals, which have resulted in greater resilience, empathy, and psychosocial orientation while reducing burnout. We will introduce principles of mindful practice through formal and informal contemplative practices, narrative and appreciative inquiry exercises, and research on mindful practice training for clinicians—building on intellectual foundations outlined in two seminal articles in JAMA (Epstein, 1999; Krasner et al., 2009) and Academic Medicine (Beckman et al., 2012). The workshop will address noticing suffering and responding to it, building on themes addressed in prior AAHPM sessions. After discussing principles of mindful practice, we will explore ways clinicians notice and respond to suffering including “fixing,” “compassionate solidarity,” and “transformation.” We will introduce brief secular, contemplative exercises to draw attention to bodily sensations, thoughts, and feelings to promote self-awareness and awareness of one’s environment. A narrative reflective writing exercise will focus on personal clinical experiences related to suffering and “turning toward suffering”; participants will take turns telling and listening to each other’s stories using techniques of reflective questioning. Next we will address ways in which mindfulness can be applied to clinical practice. Finally there will be discussion about how to grow and sustain mindful practice in participants’ own work settings.

The first carotid endarterectomy

The first carotid endarterectomy

Optimizing clinical outcomes resulting from glucose‐lowering therapies in type 2 diabetes: increased confidence about the DPP‐4 inhibitors and continued concerns regarding sulphonylureas and exogenous insulin

Optimizing clinical outcomes resulting from glucose‐lowering therapies in type 2 diabetes: increased confidence about the <scp>DPP</scp>‐4 inhibitors and continued concerns regarding sulphonylureas and exogenous insulin

Introducing the JAMA Guide to Statistics and Methods

Original research articles in JAMA are selected for publication because the results are valid and findings provide important new clinical, research, or policy-related insights. To be current, clinicians must read and understand the primary research literature. By implication, this means also understanding increasingly complex methodologies and statistical analyses now used in clinical research. Clinicians may not be familiar with research methods introduced after they completed training. Because relatively little emphasis is placed in medical school on research methods and statistics, clinicians may never have learned enough about these topics to properly understand current research articles.

CVS to phase out tobacco sales, launch smoking cessation program

Calling the decision "simply the right thing to do for the good of our customers and our company," CVS Caremark will stop selling all tobacco products at its more than 7,600 CVS/pharmacy locations by October 1. The February 5 announcement came a week after the U.S. Surgeon General issued renewed warnings about tobacco use on the 50th anniversary of the Surgeon General's landmark report linking smoking and poor health.

End of the Joint National Committee Heritage?

The National Heart, Lung, and Blood Institute (NHLBI) provides global leadership for a research, training, and education program to promote the prevention and treatment of heart, lung, and blood diseases and enhance the health of all individuals so that they can live longer and more fulfilling lives.1 One of the activities of NHLBI has been to appoint a Joint National Committee (JNC) to oversee the publication of reports for the prevention, detection, evaluation, and treatment of high blood pressure (BP). The first JNC report was published in 1976, with subsequent reports published every 4 to 6 years with the last one, JNC 7, being published in 2003.2 JNC 8 has been long awaited, having been variously dubbed JNC-late and JNC-wait. Well it has arrived, a decade after its predecessor, in the Journal of the American Association [ JAMA ],3 where it has been ushered in by no less than 3 editorials.4–6 But is this JNC 8? Is it the successor to JNC 7? If we read the title of the JAMA article carefully there is a clue to what may be described at best as subtle deception: “The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8).”3 Compare this with the title of JNC 7, which was “National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.”2 All but the most skeptical readers would assume from the recent JAMA title that what they were about to …

Are we being seduced by a robot?

My partner was seduced by a robot! An excellent physician, great laparoscopic surgeon and blossoming academic urologist was lured from a “people-orientated” academic practice group by an impersonal machine of cold steel, gears and circuits. I realize that my younger colleagues embrace Facebook and Twitter as a means of social intercourse, but how does a technological automaton in another province affect my practice and my profession? Are these dehumanizing techno-idols the future of our profession? In a recent article in JAMA, Leff and Finucane explored the “gizmo idolatry” that has swept not only urology, but the entire medical profession.1 They argue against the general implicit conviction that a more technological approach is intrinsically better than one that is less technological; there actually is strong evidence to the contrary. What are the factors promoting this techno-envy that has gripped my colleagues, making them do almost anything to belong to this new “robot club”? I am absolutely sure that it cannot be only the “bells and whistles” associated with robotic surgery; it’s certainly not overall better outcomes, quicker surgery or even reduced costs. I think it is the nebulous allure of new technology that drives us from our usual rational assessment of cost and benefits. They believe it confers on them a sense that they are truly on the “cutting edge” of our profession. The robot is certainly not about patient care, unless giving the patient what he thinks he wants based on advertisements and promotion is a part of our patient care mandate. It’s certainly not about costs, since no one in Canada (or the U.S. for that matter) has ever been able to make a business plan that has the robot saving the health-care system money. And perhaps there is even harm, in terms of our duty to the public trust, in our fanatical rush to get in line for a new robot. In a potent analogy of the Titanic and the iceberg, Anthony Zietman recently pointed out that when the unpredictable yet completely avoidable collision came, it was the hubris of technology that fared worse.2 I believe we are about to witness a collision between the robotic haves and the robotic have-nots. The robotic advocates will be driven by powerful market forces, high-stakes investment and advertising, while those who will never own a robot will only have the hard, cold and unyielding laws of nature and economics to support them. Can or even should we do something to change our destiny? We do have to acknowledge that the robot is not an experimental therapy but a legitimate form of treatment for localized prostate cancer that has some theoretical advantages over non-robotic surgery. But before we become enraptured with this approach, we must examine the benefits and the costs. No one has been able to convince me that patients operated on with a robot end up with a significantly better long-term outcome in terms of eventual cure and/or morbidity compared to standard open and/or laparoscopic procedures. The only surgically related argument my colleagues who have embraced the robot have told me is that it is sexier, more fun and easier. Seduction may be easy, fun and gratifying, but succumbing has a price—particularly if the seductress’ virtues are questionable. If however, the benefits are shown to be so obvious that all patients requiring prostate surgery must ethically have it done with a robot, we must then pay for it out of available resources, perhaps regionalizing robots in geographical centres of robotic excellence. If however, the costs are too high for the perceived benefits, then we must decide not to be lured on to this bandwagon. Our idolatry of robotic technology could lead to a significant distortion of health care, a draining of scarce financial and urological resources, a redirection of hospital priorities and budgets, possible over-treatment of patients and perhaps, eventually, problems in training urological surgeons for a non-robotic environment. I do not believe that only urologists with a robot can claim expertise, competence and pre-eminence in our profession. A combination of avarice, heroism, credulity and idolatry has imparted considerable momentum to the early adoption of this exciting technology in Canada. The robot has really seduced us. Like many affairs, we may wake up some morning and realize that the cost of our infatuation may not have been ultimately worth it. Although I now understand our fascination and idolatry with the machine and fully realize the dangers to myself and my profession, I, too, am enamoured of and even bewitched by the robot. If the mechanical lady comes calling, I fear I could be seduced as well.

The Historical Development of AMA Guides Impairment Ratings for Asthma

Abstract In 1956, the Board of Trustees of the American Medical Association convened an ad hoc Committee on Medical Rating of Physical Impairment that published thirteen articles in JAMA between 1958 and 1970, including one on pulmonary impairment rating on November 22, 1965. That article rated pulmonary impairment by radiographic abnormalities, the historical description of the degree of shortness of breath, the results of at least two of three spirometric tests (forced vital capacity, forced expiratory flow in one second, and the maximal ventilatory volume), the maximal ventilatory volume, and oxygen saturation (if performed). Use of the examinee's history has come full circle from being part of the impairment rating process to being excluded to being reintroduced in the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition. The concept that asthma is not easily rated using methods applicable to other pulmonary diseases was introduced in the fifth edition and was modified for use in the sixth edition. Since the publication of the fifth edition, several medications have been approved for treatment of asthma. Future editions likely will refine the medication usage table to reflect medications in clinical use at the time and, one hopes, also will eliminate the clumsy reference to “beclomethasone equivalents” and are likely instead to reference low, medium, and high doses of the inhaled corticosteroids.

Teaching Evidence-Based Medicine in Resource-Limited Countries

TWO DECADES HAVE PASSED SINCE THE 1992 PUBLICAtion of the JAMA article that posited evidencebased medicine (EBM) as a new method of teaching the practice of medicine. During this period, EBM has been accepted by many national and international bodies as a standard for accreditation of undergraduate and postgraduate medical education. However, incorporation of EBM into the teaching and practice of medicine has not achieved universal success. Residency programs in most resource-rich countries have attempted to incorporate EBM in their teaching. In the United States, the Accreditation Council for Graduate Medical Education mandates the teaching of EBM, through the core competency of “practice-based learning and improvement.” Despite the mandate and availability of adequate resources, the teaching of EBM faces many challenges. These include inadequate and unprotected instructional time, lack of awareness of EBM resources, lack of trained and motivated faculty, and insufficient funding. Having a faculty EBM champion in a department is an asset for effective implementation of EBM teaching in residency, but such trained, motivated, and confident faculty are not available in all places. Thus, there is lack of uniformity in the extent and depth of EBM training across various residency programs. To overcome this problem, the European Union–EBM Unity Project has developed a clinically integrated course for teaching the trainers of EBM who supervise postgraduate medical training. The course seems to meet the criteria for a successful continuing professional development course, but its effectiveness is uncertain. Despite limitations, teaching EBM in developed countries is characterized by established national and institutional recognition, continuous improvement, and steady progress. In contrast, the feasibility of teaching EBM in resource-limited settings is unclear. However, EBM is at least equally and arguably more relevant for low-middle– income countries, because this knowledge empowers health care practitioners to recognize valid and clinically important evidence relevant to their practice. Practitioners in resource-limited countries may accept without question the research results emerging from resource-rich countries. This puts clinicians in these countries at risk of prescribing drugs that may not be effective for the patients under their care, most of whom may be poor and uninsured. At the same time, under the burdens of large patient loads and lack of resources, the practitioners are at substantial risk of being out of date and providing poor quality of care. Evidence-based medicine has an important educational role to play in ameliorating this situation. The EBM process is a method of lifelong learning and problem solving. Training current and future practitioners in EBM can help them to remain up to date and provide effective protection against misleading medical literature and misconceived marketing pressures. Ability to analyze the quality of evidence and to correctly conceptualize the benefit-risk and benefitcost ratio of a health care intervention can empower clinicians to optimize value for money for their patients. Practitioners, residents, and students, equipped with the knowledge and skills of critical appraisal, can form independent views based on validity and on generalizability of research results from other countries. Feasibility of EBM teaching in resource-limited countries poses major challenges. These include lack of educational resources, language barriers, unreliable Internet connections, inequity in accessing evidence, lack of a supportive environment, and inadequately trained faculty. Although 240 members from resource-limited countries were trained in EBM knowledge and skills under the International Clinical Epidemiology Network program funded by the Rockefeller foundation, this relatively limited number of faculty cannot meet the needs of more than 1200 medical schools in these countries. Innovation is required to deal with the shortage of EBMtrained faculty. One innovation is e-learning, in which learning modules are presented as videos and exercises are computer based. Combining this approach with appropriate e-resources makes it suitable for integration with clinical practice. E-learning appears promising, but consistent with the principles that EBM espouses, any innovation in EBM teaching and learning should be adopted only if its testing

Lifetime Risk of ESRD

Lifetime Risk of ESRD