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.

Source: http://www.ncbi.nlm.nih.gov/pubmed/2695252...

COVER FEATURE: Dr Otte/Less is More Medicine in Canadian Family Physican

It is a pleasure to announce that the March edition of the Canadian Family Physician (CFP) almost entirely consists of articles that pertain to the 'right amount' of medicine; among them is a cover story about me (Jessica Otte) and Less is More Medicine.

Check out the cover article for yourself!

The CFP has recently shifted their covers to feature physicians who are practicing social accountability in medicine. It was an honour to be featured and, in so doing, bring attention to the need for real patient-centred care and consideration of the harms of too much medicine.

This month's journal is a seminal edition for the fight to find patients the right health care, thanks to the other related articles showcased:

Coccidiomycosis and other "Zebras" in Medicine; reconciling with Less is More

This is the first time I've had a peer-reviewed article published. Shortly after I wrote an email to the patient, the subject of this case report, to let him know, I was looking through my other emails and realized not only was it published, but that it had become the cover story for this of the British Columbia Medical Journal (BCMJ)!

Read the article here: A textbook case of coccidiomycosis (web version or a PDF version).

Ok, perhaps I shouldn't be so proud as it's not the Lancet or BMJ, but I think the BCMJ is pretty darn good and it was exciting for me to get to share this case in so doing, to make good on a promise to this patient to educate others about his diagnosis. It was also great to work with a friend, the very smart Dr Barlow!

I also liked the reflective exercise of thinking about how a "Less is More" kind of doctor could still diagnose exotic conditions.


The article is about an uncommon fungus (coccidiomycosis) that a patient I saw in on Vancouver Island had acquired. There's an expression in medicine:

"When you hear hoof-beats, think horses, not zebras."


One should never jump to the exotic diagnosis. However,  occasionally, people do have exotic diagnoses.

Even though I had to order some specialized tests to find out for sure what he had, this practice is still consistent with the "Less is More" philosophy. The idea is that in avoiding all the unnecessary stuff, we can use our time and resources wisely to order the RIGHT tests and treatments. It also helps immensely when patients are aware of their own health and can tell us their story clearly.

It all worked out because we had:

- A clear patient, advocating for himself, open-minded & contributing to my assessment and plan
- A doctor with time to hear the patient's story, medical knowledge appropriate for the situation
- Judicious ordering of tests (wrong test for most people, the RIGHT test for him)
- Confirmation of a suspicion gained from the history and reviewing the labs/xray that were already available

This was a highly satisfying case. I'm rarely clever, and rarely have a patient who is as good a historian as he. It's a wonderful illustration of a working acute care system, the benefits of being a patient who takes ownership for his health, and that some obscure knowledge is tucked away in my brain which will sometimes emerge when needed!