I recently joked that I could Tweet everything that I learned in medical school that turned out to be supported by evidence. As my career begins, I see that evidence-based medicine trumps much of what I was taught, and certainly what is considered “correct” on the boards.

So, what does a medical student or resident do when EBM is being ignored?

Can changes we all want to see come from “below”?

Most of the learning that goes on in medicine flows from attending to resident to student – as it should. But when an inexperienced resident or student attempts to influence patient management by citing EBM, it can be challenging to do so without seeming insubordinate or just coming off like an obnoxious “know-it-all.” But what if the resident or student is acting on expert knowledge, however newly acquired it may be?

This is what I call “change from below, from above.”

In short: newer clinicians citing expert research or EBM to their attendings.

Last fall, I learned about something called the HINTS exam (head impulse, nystagmus, and test of skew), a three-part physical exam sequence that studies show to be more sensitive than MRI at predicting posterior strokes in patients with certain neurologic symptoms. I learned these techniques from the masters themselves, albeit indirectly. I first heard about the HINTS exam on Scott Weingart’s Emcrit Podcast. Then, I read papers from David Newman-Toker’s group at Johns Hopkins and watched how-to videos. In short order, I had progressed from almost zero knowledge to extremely knowledgeable on a particular clinical scenario just by doing a little “adult learning.”

Days later, as luck would have it, two patients rolled into the ED where I was a sub-intern with similar presentations of acute-onset vertigo. Here was my moment! I did the HINTS exam on both patients. The first patient had a reassuring exam. The data suggest that this patient was extremely unlikely to have had a concerning central cause of her vertigo. In contrast, my second patient had an exam consistent with a worrisome central etiology, likely an insult to posterior circulation.

If the literature is correct, only one of these patients needs an MRI. Of course, both got them.

The scans confirmed my HINTS exam findings. One was discharged with labyrinthitis, and one was admitted to neurology. As a fourth-year student, I mentioned my findings to my seniors as an “interesting curiosity.” Frankly, they weren’t too interested. So I shut up (which is hard for me). I knew not to presume to advocate that my exam findings alter patient management because, after all, I was not even an M.D. at that point. Perhaps I should have. After all, I had just learned this stuff from the experts, via primary literature, reviews, and videos. I knew that my findings implied vastly (and clinically significantly) different odds ratios for my two patients.