Clinical Q&A: making a difference in practice
CMAJ 1998;158:932
© 1998 Canadian Medical Association
CMA Online turned 3 last month. As it enters its 4th year it has a fresh look and major new services, including the fully online Journal of Psychiatry and Neuroscience and the CMA's first Web-based members-only service, OSLER, which was described in the last issue (CMAJ 1998;158[6]:799).
But for some physicians, the very first service added to the infant Web site in 1995 — Clinical Q&A — remains the most clinically relevant feature of CMA Online. This "mailing-list discussion group" has evolved into a network of close to 300 physicians in Canada and around the world.
It is the only listserv that Dr. Michelle Greiver of North York, Ont., belongs to, and she says the fact it is restricted to physicians results in "rich freedom of expression that allows a fair amount of technical material to be brought forth."
She says the level of discussion has remained high and even controversial subjects "can be discussed in a nonthreatening manner, with different points of view expressed and respected."
Meanwhile, Dr. Cyril Sherer says Clinical Q&A has become a valuable part of his general practice in Jerusalem, where he has practised since emigrating from New Zealand in 1961. Although he has run a weekly journal club from his office since 1971, he says Israel has nothing to compare with Clinical Q&A.
Useful at the bedside
"I am very impressed with the level of knowledge shown by the members," he says. "These are serious people, deeply concerned with practising better medicine. I have also been impressed that there is concern about ethical problems as well as clinical ones."
Ann Bolster, the CMA's associate director, online and information services, says Clinical Q&A is considered such a success that additional forums — some public and some private — are being planned for CMA members. "We also hope that 'real-time chat' will be available through CMA Online before long. The Members Only section will be the gateway to most of these forums."
In the meantime, Greiver will continue posting comments every 2 or 3 weeks, and learning in the process. "It is useful to see how colleagues deal with clinical problems in the reality of their practices," she says. "I've learned a lot. In December 1996 I treated a patient using advice gleaned directly from the group because a MEDLINE search did not lead to a clear path for this patient's care."
Greiver followed the advice she received concerning record-level hypertension and posted the results of ongoing treatment and investigations as they became available. "The outcome was excellent."
Threading the needle
A series of Clinical Q&A messages dealing with the same topic is called a thread. Discussion on a single topic can last a week or more before an issue is talked out. A recent one began with a physician's call for advice about a 43-year-old bus driver who appeared in his office smelling of alcohol and admitted to drinking several beers a day. Laboratory results showed a very high level of ethyl alcohol, and the physician wondered if he should report the patient to the transportation ministry because of the potential threat to bus passengers.
"Do you have any evidence to substantiate chronic alcoholism or actual impairment?" asked one physician, who recommended a go-slow policy. However, other participants urged the doctor to report the patient. "Would you like you or your child to ride on his bus?" said one. "Your responsibility to the protection of the public supersedes the physicianpatient relationship."
"Report the facts," added another, "and let the ministry sort it out." Another participant agreed, noting that reporting rules for all provinces are posted on CMA Online and physicians are explicitly protected from liability for reporting a patient. "I came to the same conclusion," responded the doctor who launched the discussion, "and reported him today."
How to subscribe
To subscribe to Clinical Q&A, physicians must send a signed letter written on professional letterhead. This can be sent by fax (613 523-0937) or mail (Dawna Ramsay, CMA Online Webmaster, CMA, 1867 Alta Vista Dr., Ottawa ON K1G 3Y6). Applicants must indicate their email address and CMA membership number; nonmembers must provide their licensure number.
Michelle Greiver is glad she joined. "I guess you could say I'm a real fan. It has made a difference in the way I practise." — Patrick Sullivan
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