No evidence that N95 respirators are better than surgical masks

From NinjaCat14 on  Deviant Art  I can't make this stuff up!

From NinjaCat14 on Deviant Art
I can't make this stuff up!

Specialized technologies are always sexier than their basic alternatives.

We often think that new and complicated is better. Or that if something is more expensive if must work better, right? 

One small trial found that a more expensive placebo was much more effective than the cheap one in Parkinson's patients. There is a lot of interesting research around how cost influences thinking and choice, and much of it is applied by manufacturers to influence their markets (see for example: Relative thinking in consumer choice between differentiated goods and services and its implications for business strategy).

Sometimes we think again about something that is not new, but an existing technology or process that we just use by habit, having assumed for years that it was better than the alternatives. Rarely are these things scrutinized, but sometimes when they are, we find out we are  "all wrong." For example, we have long assumed that acetaminophen is helpful for lower back pain but a meta-analysis in the BMJ in March 2015 found this is not the case.

In a recent Canadian Medical Association Journal (CMAJ) article, Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis, we learned that there really is not a lot of clinical research that supports the effectiveness of N95 masks. In the lab, yes, surrogate markers suggest the N95 masks could be "better" than normal surgical masks, but the data in practice is so lacking. 

Smith et al. concluded that "Although N95 respirators appeared to have a protective advantage over surgical masks in laboratory settings, our meta-analysis showed that there were insufficient data to determine definitively whether N95 respirators are superior to surgical masks in protecting health care workers against transmissible acute respiratory infections in clinical settings."

Of course 'insufficient data' doesn't mean we should abandon these masks. While I will still wear N95s for seeing TB patients and for performing high risk interventions on patients with influenza like illness, I now begin to wonder if this is really necessary.

There are so many 'fancy' technologies that we have discovered are no better than the old ones, and our knowledge of the waste, cost, and sometimes harms associated with them makes it hard to  not carefully scrutinize every 'new alternative' and 'innovation.' 

As I head to Toronto for a meeting of the CMA's Joule Innovation Council this week, I must laugh a bit. I imagine my experience in critical review of medical literature and knowledge of the harms from overtesting/treating/diagnosis, will make me one of the toughest judges of our colleagues' submissions! We are reviewing grant proposals for development of innovations from Canadian physicians.

I hope that with this privilege, I can be both enthusiastic and measured in my assessments, though I won't be surprised if I'm one of the more, uh 'fiery,' of the dragons in the den. With the collective wisdom of the group, I'm certain we will support some elegant, thoughtful, and effective innovations to make a positive difference for patients and health care systems.


Doctors' grade: C- on #ChoosingWisely Test Your Knowledge Questions in CMAJ

Fascinating results emerge from a small online poll of Canadian Medical Association Journal (CMAJ) readers. Web polls on the CMAJ site were done over the span of 7 months and the following 12 True or False questions were asked.

Although not scientific, the results tell us that (at least mildly-) engaged physicians (those going to the CMAJ website) like to provide a lot of unnecessary and harmful care, particularly in the area of diagnostic imaging.

Not only do we need more research on why physicians think this way, we also need research on what methods are effective at changing behaviours. We don't know yet if Choosing Wisely-type outreach to patients and providers can improve practice. We think and hope so . . .

See the Choosing Wisely Canada update for more.


*NB: Dr S.P. Landry has a keen eye and noticed an error; for the item pertaining to "All children with head trauma require imaging to rule our fracture and brain injuries" the answer should be FALSE. So, the correct response rate would be 70% on that question, making the overall score of respondents a little less terrible, but still remarkably bad ;)


Focus on Choosing Wisely Canada from CMAJ

Choosing Wisely Canada and the Canadian Medical Association Journal (CMAJ) have teamed up to create this excellent digital book. It includes background information on the campaign and why it exists, practice cases which highlight unnecessary or harmful tests & treatments, and guidance on five clinical topics. There are also true or false questions that test your knowledge about which medical interventions are warranted.

This digital book is a really cool way to get familiar with the campaign and might be a fantastic manual for teaching. Have a look:


Doctors warned not to encourage young women to freeze their eggs

Aging is a normal part of human existence.

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As we age, parts of our body change the way in which they work - or stop functioning all together. For women, natural aging means a slow down and then a stoppage in our ability to be fertile.

With women increasingly devoting the early part of their lives to establishing a career, many are delaying pregnancy. Some are freezing their eggs for later use. Physicians, employers, and society as a whole are starting to encourage this practice.

This is troubling in a few ways. Drs Petropanagos and colleagues write (in the CMAJ) that it raises some significant social implications, reinforcing that "motherhood is a central aspect of womanhood." 

Egg freezing as a way of preserving women’s reproductive options reinforces the social norms and expectations that construe motherhood as a central aspect of womanhood. Women are encouraged to freeze their eggs as a way to “have it all” (that is, to have both a family and a career), implying that for those women who want both these things, egg freezing makes this possible. Although individual women may benefit from egg freezing to satisfy their reproductive desires, physicians should not assume that having a genetically related child is equally important to all women who ask about social egg freezing.

Our bodies do things for a reason. Delaying pregnancy and then using frozen eggs exposes women (and their new children) to greater and greater risks, due to complications of pregnancy and childbirth. 

Fighting the natural changes makes aging a 'medical problem' rather than a part of our existence that we can embrace and accept. I agree with the authors' suggestion that there are better solutions, like funded child-care, that could enable women to really have a choice when it comes to balancing motherhood and a career.

Read the National post article here, or the original CMAJ article here.


CMAJ Interview: Choosing Wisely Campaign Well Received

I had the great opportunity to be interviewed about the Choosing Wisely Canada campaign this week by CMAJ writer, Wendy Glauser: Choosing Wisely Campaign Well Received.

It was a positive experience, and it looks like I need some interview practice! For the record, I'm very excited about the Choosing Wisely Canada release and about the fact that this is coming from the Canadian Medical Association (CMA). The CMA works very hard at health advocacy on a national level, and I think this is an exciting campaign because it reaches patients as well as healthcare providers.

I think Dr. Nancy Morden makes an important point  - a lot of the Choosing Wisely information has been around for a long time. The gap is in the adoption of it, and I am optimistic that because of the reach of this national campaign, we'll see more physician uptake, and we'll see more patients educating themselves and bringing questions about "do I really need this test or treatment" to their doctor, NP, pharmacist, etc..

Ms Glauser and I had a long conversation about how the recommendations are an excellent start, a small part of a broader cultural shift, and how I am delighted with the Family Practice and particularly Geriatrics recommendations as I use some of these daily in my work as a hospitalist. I also tried to emphasize that the recommendations create great points of discussion with patients, nurses, and allied health staff. I think the key to this campaign is in starting really great, patient-centrered discussions, and 'thinking twice' about the tests and treatments that may be undertaken.

As far as the nursing point I spoke of, I tried to indicate that the practice of overuse of benzodiazepines and antipscyhotic sedatives is an area that we are constantly working on.

We all know that nurse to patient ratios have become unfortunately extremely challenging for good care. The nurses are more than qualified to assess and treat their patients expertly, however, if a nurse has 8 patients and half of them are confused, it becomes a real challenge to keep close tabs and achieve safety for each. When all is done to prevent confusion or delirium, there are still patients who will - because of underlying illness - become agitated or aggressive, to the point of potential safety issues such as harming themselves, other patients, or caregivers, interventions of some kind are required.

We often receive calls about delirious patients at night, and sometimes these requests are specifically for sedative medication. The first treatment is to use environmental means, reorientation, and to correct the underlying medical cause for the acute state of confusion. However, it's not uncommon to have requests for medication, and physicians - and now the Choosing Wisely campaign - are responsible for educating nurses as well as patients about the risks of these medications. Personally, I respond to almost all phone calls requesting benzodiazepines for elderly patients with a discussion of alternatives, why benzodiazepines are likely contraindicated, and together with the nurse, develop a different approach. For antipsychotics, I tend to emphasize the cardiovascular risk, avoid where possible, and if needed, use the lowest dose available writing "use PRN (as needed) sparingly for aggression and agitation." Nurses respond very well to these discussions and often help by offering other creative solutions for helping manage patient behavior without medications.

With these as with all treatments, we need to think carefully about the other options, the benefits and harms, and use them only in the right contexts, with frequent re-evaluation.


Of course economics is a factor in Canadian Health Care. I believe that good care has to come first, and if economic benefits follow, that would be a fortunate result. Perhaps with any savings from our new found focus on ordering appropriate tests and treatments, we can invest more in areas of our system where patients are marginalized, under-supported, and under-cared for.

Physicians and patients will be driven to follow the recommendations and spirit of Choosing Wisely because it is the right thing to do, to empower patients to achieve their health care goals and to minimize the harms of unnecessary interventions along the way. (I wish that had made it into the article!)

I want to support the Choosing Wisely recommendations wholeheartedly as just that - they are not "rules" - but rather recommended points for reflection and dialog. The key is that we must carefully consider each thing we do, and the majority of the time, our practice will fall under these very clear suggestions from our National specialist bodies. Fortunately, Dr. Rick Glazier seems to have made this point clear; there are always exceptions to recommendations, and guidelines are to guide us intelligently, not to restrict practice unilaterally or to get in the way of 'good medicine.'

These suggestions of this Campaign will stimulate worthwhile and illuminating conversations with patients and ultimately, care must be tailored to the context, needs, and goals of our patients. That's how Choosing Wisely Canada will help guide excellent care for Canadians.