Clinician Profile – Dr Steve Flecknoe-Brown: Wide Bay’s evidence warrior

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Evidence-based practice is in the DNA of the Clinical Knowledge Network. Embracing this approach – the integration of clinical expertise, patient values, and the best available evidence to deliver improved patient outcomes – is critical for every clinician in the state.

Today we speak with one of the champions of evidence-based practice, Dr Steve Flecknoe-Brown (FRACP, FRCPA, FRSM), District Director of Clinical Training in the Wide Bay HHS.

For the past 18 months Dr Flecknoe-Brown has also been Acting Clinical Director of Medicine at Bundaberg Hospital. His varied experience has covered roles spanning metro, regional, and remote areas of NSW and Queensland.

Prior to his current roles Dr Flecknoe-Brown had spent 16 years in a highly-specialised haematology practice in Sydney, followed by the same amount of time as Director of Clinical Training and Senior Consultant Physician at Broken Hill, in the far west of NSW.

Dr Flecknoe-Brown has held a seat on the MIMS Honorary Editorial Board since the late 1980s, served on the National Blood Service’s Patient Blood Management Steering Committee, and is a current member of the DynaMed Plus Super User program.

My role as District Director of Clinical Training involves overall responsibility for the first two years of post-graduate training of Australian Medical Graduates and the first year of experience of International Medical Graduates in Australia in the district’s hospitals. As you could imagine, this involves more than just supervision of their induction into ward-based medical work.

We need to continue to instil into them the values of life-long learning and professionalism, as well as ensuring that they successfully negotiate this transition period in their lives. The last of these is the most subtle and important of all. They have put a lot into getting this far, and the taxpayer has paid a lot as well. We know that the time can be emotionally challenging, so we must achieve all of this training whilst monitoring their wellbeing and supporting them through some difficult experiences.

In my acting role as Clinical Director of Medicine, I am charged with the responsibility of maintaining that fragile bridge between medicine and management. The easy part is convening Journal Clubs, Grand Rounds and Morbidity & Mortality meetings. The part that doesn’t come easily to most medicos, but is absolutely vital, is to understand the needs of the managers of our complex health system and to ensure that the voice of the doctors and their patients is always heard clearly when management decisions are made.

“We are all supposed to practice evidence-based medicine
but sadly this is often not the case.”

Sometimes this is because medical leaders have inflexible opinions; sometimes it is because evidence is lacking; sometimes it is because Clinical Guidelines are based on flawed evidence. Some years ago a critical analysis of US-based consensus guidelines, for example, concluded that only a minority were based on sound evidence. Thus, although our team bases clinical decision-making on local guidelines, we know that we must constantly interrogate the evidence upon which those guidelines are based.

Not only is the quantum of published literature increasing exponentially, but the range of research methods is constantly growing. For example, good quality qualitative research is now much more frequently published than it used to be. In amongst all that data there is likely to be a lot of noise and, regrettably, some deliberately misleading information. With the growing pressure in academic centres, the temptation to publish incomplete or misleading data will only increase. This means that our scrutiny of each apparently important publication must become increasingly stringent.

My appointments with MIMS and the National Blood Service have given me deep insights into the varying quality of evidence as presented in the medical literature and how best to critically assess this evidence. In my current roles in the Wide Bay, this is put into practice by helping ensure that our trainee doctors develop their critical skills when dealing with the published literature. I am particularly proud of this unique contribution that I make to their professional development.

Relying on CKN’s tools to uncover the evidence

It was immediately obvious to me that CKN’s primary decision support tool, DynaMed Plus (DMP), provides extensive links to the published literature and clinical guidelines. This encourages the user to ‘go deeper’ into the evidence, which is exactly what I aim to do for my trainees and colleagues in the Department of Medicine.

To ensure the maximum value out of the DynaMed Plus resource, it became obvious that I should become very familiar with its capabilities, so I gladly accepted the offer to become part of the DynaMed Plus Super User program. Unexpectedly, this also brought me into the international community of DMP Super Users. I am kept in regular touch with developments in the DMP platform and have had the opportunity to actively contribute to the content. Personally, this has been very gratifying.

Increasing the use of DynaMed Plus as a bedside decision-support tool will continue to focus the attention of users on the actual evidence behind the recommendations, encouraged by the efforts of the Super User community. Making this discipline part of daily business in the wards will imbue trainee doctors with good habits of self-reflection and critical thinking.

Seeking and interrogating the evidence has always been part of my practice. For me, DynaMed Plus has made access to the evidence easier and so I am more productive. For example, research is not my core business, so I tend to be a ‘late adopter’ of new therapies. If, however, I propose adopting a treatment regimen which the current literature indicates is better than what I am used to, I always look at DynaMed Plus to see what the community of my peers has said about it. I can remember a recent case of myeloma where this is just what I did, and was very satisfied with the results of treatment. On the other hand, for a young man with newly-diagnosed Hodgkin’s disease, I could not find compelling support for a change in practice even though a lot of new ‘salvage’ treatments have been reported recently.

In my teaching and leadership roles, DynaMed Plus has allowed me to offer a resource which encourages the learner or practitioner to actively pursue the answers, rather than being handed them passively. This fits well with the principles of adult learning. In seeking the information, there are always some by-ways to be explored, which encourages deeper learning than the surface-skimming encouraged by opinion-based publications.

"The decision by Queensland Health to provide CKN to all clinical staff as part of their employment package is an enlightened one."

CKN is there in the wards on every Queensland Health computer. The user, with only a little bit of practice, can learn to quickly navigate to the clinical decision-support relevant to the challenge in hand. I encourage all my interns and RMOs to quickly check their decisions whenever feasible, whether by reference to the electronic Therapeutic Guidelines (eTG Complete) or, for deeper learning, DynaMed Plus.

Similarly, it is only when you have been writing prescriptions for many years that you should take the chance of writing up a new medication without checking its entry in MIMS or the Australian Medicines Handbook.

There is also quite a good range of ebooks and journals available for reference if needing to cite a key reference in a report. Most of the successful Registrars also use CKN to browse current journals like the New England Journal of Medicine, JAMA and BMJ if they have any spare time on evening or night shifts.

I believe that a culture of continuous learning and evidence-based practice will become the norm in Queensland Health as a result of ready reference to the resources of CKN. And I do hope that the DynaMed Plus Super User group will be able to foster critical examination of the evidence behind the guidelines.

Photo credit: Gavin Schmidt

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