I recently joked that I could Tweet everything that I learned in medical school that turned out to be supported by evidence. As my career begins, I see that evidence-based medicine trumps much of what I was taught, and certainly what is considered “correct” on the boards.

So, what does a medical student or resident do when EBM is being ignored?

Can changes we all want to see come from “below”?

Most of the learning that goes on in medicine flows from attending to resident to student – as it should. But when an inexperienced resident or student attempts to influence patient management by citing EBM, it can be challenging to do so without seeming insubordinate or just coming off like an obnoxious “know-it-all.” But what if the resident or student is acting on expert knowledge, however newly acquired it may be?

This is what I call “change from below, from above.”

In short: newer clinicians citing expert research or EBM to their attendings.

Last fall, I learned about something called the HINTS exam (head impulse, nystagmus, and test of skew), a three-part physical exam sequence that studies show to be more sensitive than MRI at predicting posterior strokes in patients with certain neurologic symptoms. I learned these techniques from the masters themselves, albeit indirectly. I first heard about the HINTS exam on Scott Weingart’s Emcrit Podcast. Then, I read papers from David Newman-Toker’s group at Johns Hopkins and watched how-to videos. In short order, I had progressed from almost zero knowledge to extremely knowledgeable on a particular clinical scenario just by doing a little “adult learning.”

Days later, as luck would have it, two patients rolled into the ED where I was a sub-intern with similar presentations of acute-onset vertigo. Here was my moment! I did the HINTS exam on both patients. The first patient had a reassuring exam. The data suggest that this patient was extremely unlikely to have had a concerning central cause of her vertigo. In contrast, my second patient had an exam consistent with a worrisome central etiology, likely an insult to posterior circulation.

If the literature is correct, only one of these patients needs an MRI. Of course, both got them.

The scans confirmed my HINTS exam findings. One was discharged with labyrinthitis, and one was admitted to neurology. As a fourth-year student, I mentioned my findings to my seniors as an “interesting curiosity.” Frankly, they weren’t too interested. So I shut up (which is hard for me). I knew not to presume to advocate that my exam findings alter patient management because, after all, I was not even an M.D. at that point. Perhaps I should have. After all, I had just learned this stuff from the experts, via primary literature, reviews, and videos. I knew that my findings implied vastly (and clinically significantly) different odds ratios for my two patients.

On this one question, I happened to know more than my seniors, even though I recognize that this is rarely the case. Several weeks later, Dr. Michelle Lin happened to post an article on

her academiclifeinem.blogspot.com extolling the HINTS exam. I excitedly wrote to her that I loved the exam but felt that my higher-ups hadn’t heard of it and would think I was crazy for suggesting that it guide patient management.

Dr. Lin’s response is informative: “That’s awesome. Before a few weeks ago, I would have looked at you as crazy as well. Any tips for success?” Dr. Lin’s comments are what I might expect. On the one hand, she is keen to identify cost-saving EBM measures she can use in her practice. On the other, she acknowledged that if this information had come from a student, she would have been less receptive. Even armed with odds ratios and validated studies, I would had little chance to introduce rational changes in the ED.

But once I demonstrated to Dr. Lin that I knew something about the topic, she invited me to give her tips for success (by the way, I had none; I’ve done this exam five times ever!). The traditional hierarchy dictates that researchers/masters disseminate information to the physicians in the trenches, who teach their

residents and students. But in the era of Press Ganey scores and understaffed EDs, maybe residents and students are the perfect people to push EBM while the attendings are busy keeping the ED from falling apart.

The key is for attendings to invite new ideas and reward them. Other fields have adapted checklists into their clinical practice. Perhaps we should, too. Included in that list might be a line in which the attending asks at some point during the shift, “Are there any EBM or new papers that anyone would like to share?”

Maybe residents should be encouraged to include EBM in their assessments and plans during oral presentations. Unlike other fields, we don’t have the luxury of rounding on a patient the next day and having someone give a formal presentation on up-to-date information. We must make changes in real time, or opportunities are lost. This might slow things down initially, but it might also decrease overuse of antibiotics, remove the unsupported use of Kayexalate for hyperkalemia, and perhaps someday, avoid futile/brutal ACLS in some cases. I could go on.

But don’t take a student’s word for it. Just check out the literature!

Dr. Faust just matched into the Emergency Medicine Residency Program at Mount Sinai in New York. When he wrote the article, he was a fourth-year medical student at the Mount Sinai School of Medicine and scheduled to receive his M.D. on May 10.