#569 - The “Final Edition”: Keeping Up, Gratitude, Thanks-Giving “Angels”

From … Mark and John

1) Keeping up and Answering Questions

In a 2004 BMJ special edition about evidence-based medicine (EBM), an article provided a conceptual framework created by the authors to evaluate the “learner types” that would serve as goals medical school curricula on EBM. These learner types were doers (those who produce evidence-based materials like critical appraisals), users (those who seek out critical appraisals and other evidence-based sources of information), and replicators (those who model their practice after others who practice in an evidence-based manner).

In Take 3, Mark and I have tried to fulfill the doer role as faithfully as we could. And his original goal (as well as mine when I joined) was to support and encourage users of our synopses of the evidence. But we also attached our comments on the articles we summarized, often reflecting on our own practices, to help those who chose instead to replicate the practice we described.

As we close this chapter of Take 3, we feel an important obligation to provide some other resources that readers can use to base their practices on evidence. We hope that reading Take 3 has provided growth in using these sources…or at least will help readers have some healthy skepticism for and discipline in integrating the fire hose of new research information with their current practices.

Keeping up resources:

• The American Family Physician journal has had a long-standing commitment to making their content more evidence based. The SORT (Strength of Recommendation Taxonomy) table is important to readers to understand the basis for many of the recommendations in AFP review articles. In addition, many of the regular “departments” of the journal (Cochrane for Clinicians, STEPS, Clinical Inquiries) are the best products of the doers in Family Medicine.  In addition, for AAFP members, there is an abundance of free CME by taking the monthly quiz.
• InfoPOEMS/Essential Evidence Plus emails are daily summaries of curated and reviewed studies relevant to primary care. This subscription service has been around for decades, founded by the first family physician educators to widely popularize the EBM concepts in family medicine.
• Podcasts – three that Mark and I have been listening to (available on all major platforms):
  • Primary Care Update – this one is closest to critical appraisal of recent articles. Not the slickest audio production, but good, quick summaries of four articles and some geeky humor.
  • Curbsiders – a popular internal medicine podcast. Lots of good evidence-based medicine, but also lots of expert opinion thrown in. Very entertaining mix of outpatient and inpatient adult medicine.
  • AFP Podcast – presented by residents with faculty supervision, this is best characterized as a podcast-based summary of the AFP journal with some other fun items thrown in. An entertaining way to keep up with the AFP journal.

Question answering resources:

• DynaMed – This has long been my “electronic textbook” (over UpToDate) for its rigorous commitment to evidence-based medicine. The ability to drill down and link to the evidence behind its recommendations is the essence of EBM, in my opinion.
• The Cochrane Library – Huge database of systematic reviews with a goal of answering focused questions with a valid, reproducible systematic review methodology from the Cochrane Collaboration.
• TripDatabase.com – A long-standing “meta-search” engine that searches many places and organizes the information by evidence grade. The founder is committed to helping find the best answers as quickly as possible. Recently experimenting with incorporating artificial intelligence summaries and critical appraisal. The free version is good, the pro version gets you more access to information.
• OpenEvidenceAI – This is an exciting one. Produced by the Cleveland Clinic, Mayo Clinic and Harvard, it provides AI summaries of articles that can answer your query. It violates EBM rules by not explaining how it found the sources it does but provides reasonable summaries as well as citations of articles relevant to your questions. I have not found any “hallucinations” yet, but please keep a healthy skepticism about its answers.
• WikiGuidelines – A new resource on the block. The focus is to produce “humble” evidence-based guidelines that do not substitute expert opinion for strong recommendations. They prioritize a primary care audience as well as primary care participation on the guideline committee. They have notably published several of their initial guidelines on the JAMA Network. Largely internal medicine focused. Worth keeping an eye on.

John’s Comments:

This obviously is not a complete list, and not all of these are free. A piece of wisdom I have found very useful is: If you’re going to use a shortcut (someone else’s summary of the literature), at least use a product that itself doesn’t take shortcuts. As you are looking for other ways to keep up, review how the service produces its recommendations before buying/using those recommendations. Thank you for letting us talk evidence with you on Fridays…it’s been a great ride. Caveat lector!

References:

Straus SE, Green ML, Bell DS, et al. Evaluating the teaching of evidence based medicine: conceptual framework. BMJ. 2004;329(7473):1029-1032. Link

From the Literature and the Greater Good Science Center

2)  The Science of Gratitude

Gratitude infuses our religious, cultural, and scholarly traditions. It has been conceptualized as an emotion, a virtue, a moral sentiment, a motive, a coping response, a skill, and an attitude.  Most people have an instinctive understanding of what gratitude is, but it can be surprisingly difficult to define, as it can mean different things to different people in different contexts. 

Research suggests that gratitude is not simply a cultural construct. It has deep roots that are embedded in our evolutionary history, our brain structure and function, and in our family and social development.  Some researchers suggest that gratitude may have evolved as a mechanism to drive reciprocal altruism, thereby turning strangers into friends and allies who are more likely to help one another. Studies from neuroscience have identified brain areas that are likely involved in experiencing and expressing gratitude, providing further evidence for the idea that gratitude is an intrinsic component of human experience.

There are a variety of factors that have been linked to one’s likelihood of experiencing gratitude or having a grateful disposition, including personality, cognitive factors, and gender.  Research also suggests that social factors—including religion, cultural influences, and parenting styles—may influence a person’s tendency to experience gratitude.  Additionally, it appears that gratitude may be associated with many benefits for individuals, including better physical and psychological health, increased happiness and life satisfaction, and decreased materialism. 

Gratitude is also important to forming and maintaining social relationships.  Research suggests that gratitude inspires people to be more generous, kind, and helpful (or “prosocial”) and strengthens relationships, including romantic relationships and is associated with decreased loneliness.  Though there has not been a great deal of research explicitly focused on gratitude in the workplace, a handful of studies suggest that gratitude may help employees perform their jobs more effectively, feel more satisfied at work, and act more helpfully and respectfully toward their coworkers.

A growing number of studies have tested the efficacy of various practices (“interventions”) designed to boost gratitude, such as explicitly noting one’s blessings ("Three Good Things" exercise or gratitude journaling) and writing gratitude letters or even texts of gratitude to people whom one has never properly thanked.  A series of meta-analyses have attempted to determine the efficacy of gratitude interventions, and most have concluded that gratitude interventions do appear to significantly increase happiness, well-being, and positive mood.

Mark’s Comments:

The season of Thanksgiving always provides a wonderful backdrop for reflection on the place of gratitude in our lives.  Studies show that the feeling of gratitude is an important ingredient for overall well-being and will increase with regular practice (it’s a skill!).  Research on the science of gratitude is relatively new, and thus there are still many open questions left to explore.  If you want to get a sense of your present “gratitude aptitude” here’s a link to a gratitude quiz from Rick Hanson, PhD - Gratitude Quiz.

Reference:

Hittner J and Windholm G.  Meta-analysis of the association between gratitude and loneliness.  Applied Psychology: Health and Well-being. November 2024. 16(4): 2520-2535.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Celebrating Our “Angels” this Thanks-Giving

“Sometimes our light goes out but is blown again into instant flame by an encounter with another human being.  Each of us owes the deepest thanks to those who have rekindled this inner light.”   Albert Schweitzer, MD, Humanitarian and Nobel Peace Prize Recipient

There is a drawer where I keep cards, letters, and pictures that have been given to me over the years from patients, students, residents and colleagues, and when I’m feeling the need to be reminded of why I do this incredible but also demanding and emotionally draining work, I go through that drawer and pick out a few.  This ritual allows me to reflect on the many people who have spoken into my professional life and in doing so, helped make me “better than I am.”  Though I don’t remember someone ever advising me to save these items, I’ve learned over the years that many other colleagues have such a memento collection as well.   

Recently, after a particularly challenging day in clinic, including having to share some very sobering news about a likely terminal diagnosis with one patient and having another patient and her son expressing their anger to me regarding something that I had no control over, I was feeling in need of an uplift.  In response, I opened that drawer and allowed some of the notes and pictures to speak love and encouragement to me from across the miles and years.      

One of notes was from a dear friend and colleague, Elizabeth Vogel, PhD, with whom I worked from 2006-2009 as we created the Carilion Office of Professional Development and whose life ended very suddenly, and senselessly.  Elizabeth was one of those people whose inner light shone brightly, and her encouragement inspired the foundation for much of the work I am doing today.  The quote above was one of her favorites, and we often spoke of those people, whom she called her “Angels,” who had positively impacted our lives with their ability to see something in us that we couldn’t yet see in ourselves.  Though I didn’t tell her often enough, she was such a person for me. 

One of Elizabeth’s legacies was the inspiration she helped provide for what is now the PeerRxMed process.  She and I spoke often of the challenges of working in healthcare and of how very isolating it can be, both by choice and by design.  She often stated what has now become the obvious for me – that it is “crazy” for anyone try and navigate this professional journey on their own.  In doing so, she helped plant the seeds for the PeerRx vision that “No one should care alone.”   

All of which has left me thinking about other “Angels” in my life, past and present, and wondering about yours as well.  When was the last time we’ve thanked them for how they have positively impacted our lives?  In this season of Thanks-giving, perhaps we can all take a moment to express our gratitude to and for them – by texting, calling, or writing them, or for those no longer with us, pausing to express a prayer of gratitude.  For me, that would include my PeerRxMed partners, who weekly fan the flames of my life with their presence and their encouragement. 

Now more than ever we all need to show up as the “better versions” of ourselves, and there’s no way that’s going to happen on our own.  Fortunately, we all have “Angels” in our midst.  That’s something worth celebrating with Thanks-Giving every day ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org