On this one question, I happened to know more than my seniors, even though I recognize that this is rarely the case. Several weeks later, Dr. Michelle Lin happened to post an article on

her academiclifeinem.blogspot.com extolling the HINTS exam. I excitedly wrote to her that I loved the exam but felt that my higher-ups hadn’t heard of it and would think I was crazy for suggesting that it guide patient management.

Dr. Lin’s response is informative: “That’s awesome. Before a few weeks ago, I would have looked at you as crazy as well. Any tips for success?” Dr. Lin’s comments are what I might expect. On the one hand, she is keen to identify cost-saving EBM measures she can use in her practice. On the other, she acknowledged that if this information had come from a student, she would have been less receptive. Even armed with odds ratios and validated studies, I would had little chance to introduce rational changes in the ED.

But once I demonstrated to Dr. Lin that I knew something about the topic, she invited me to give her tips for success (by the way, I had none; I’ve done this exam five times ever!). The traditional hierarchy dictates that researchers/masters disseminate information to the physicians in the trenches, who teach their

residents and students. But in the era of Press Ganey scores and understaffed EDs, maybe residents and students are the perfect people to push EBM while the attendings are busy keeping the ED from falling apart.

The key is for attendings to invite new ideas and reward them. Other fields have adapted checklists into their clinical practice. Perhaps we should, too. Included in that list might be a line in which the attending asks at some point during the shift, “Are there any EBM or new papers that anyone would like to share?”

Maybe residents should be encouraged to include EBM in their assessments and plans during oral presentations. Unlike other fields, we don’t have the luxury of rounding on a patient the next day and having someone give a formal presentation on up-to-date information. We must make changes in real time, or opportunities are lost. This might slow things down initially, but it might also decrease overuse of antibiotics, remove the unsupported use of Kayexalate for hyperkalemia, and perhaps someday, avoid futile/brutal ACLS in some cases. I could go on.

But don’t take a student’s word for it. Just check out the literature!