Distributed Education: Dr. Donald Eby

By Luiza Moczarski, BFA'00

Curiosity is tied to life-long learning for physicians. Asking questions, seeking to know more, and solving problems are part of who physicians are.  

Curiosity led Dr. Donald Eby, and his emergency room colleagues at Grey Bruce Health Services, to ask questions about the disparity between their clinical practice and recommended guidelines for serial laboratory testing to investigate patients with chest pain. This disparity was discovered in 2015 when Dr. Ken Newell undertook a laboratory audit of the troponin-I test ordering practice of emergency physicians at two different hospital sites. Troponin is a component of cardiac muscle.  An increase in a patient’s troponin blood level is used to detect evidence of cardiac muscle damage and plays  a key role in the diagnosis of acute myocardial infarction. The audit identified a very low rate of serial troponin testing in both sites. This is at variance with current guidelines.  

Dr. Eby wanted to understand why physicians don’t follow published clinical guidelines. The Distributed Education Network pre-clerkship summer research program provided an opportunity for Brandon Belbeck, Medicine Class of 2020, to join the research team and help with the project.

The study repeated the quality assurance audit, but this time used individual physician ordering data and aggregate emergency physician group rates as the units of analyses. Emergency physicians were then individually interviewed to try to understand why they practised the way they did.  

The study found that physician practices varied widely. Physicians interpreted multiple pieces of information to form a gestalt of a particular patient’s case. Troponin testing was only one of these pieces of information. The importance placed on the troponin result depended on the context of the clinical story.

“The practice of serial troponin testing was highly variable and depended largely upon when the physician believed the process of infarction began,” said Dr. Eby. “Despite practice variations from published guidelines, individual physician practices used an internal logic that was rational and made sense of the situation to them.”

 The study generated a great amount of interest among the physicians who practice at these sites. The hope is that these findings and discussions resulting from them continue among the physicians and lead physicians to adopt a common approach to ordering Troponin testing.  

“It’s important to ask questions,” said Dr. Eby “What’s our ordering pattern? What are we doing in our own practice and our departments? And come to a consensus on how they should be doing things.”