Turning Back

Jacob Schor, ND, FABNO, AANP Conference Speaker Selection Committee Chair, proposes hiking Herman Gulch with Michael Cronin, ND, AANP President, and discusses how the speaker selection committee will choose abstracts for the 2013 conference in Keystone, Colorado. There are two things the committee hopes to find in abstracts submissions. First is whether a lecture changes the way of practice. Call this the Monday Question. Will you tell your patients something different the Monday after the conference after listening to a lecture? This second item is more elusive than the first. It is what the committee calls, “Paradigm Shifting.” Does this lecture fundamentally change the way you might view an issue related to practice?

I didn't see any hesitation in my dog Poppy's face when I suggested we turn back before reaching Herman Lake yesterday. We were just above tree-line, where the trail gets steep and the path was a sheet of ice beneath fresh wind blown powder. We were slipping and sliding with every step. My ski goggles were at home and the blowing snow was blinding me. We turned back. Do dogs sigh in relief? I know I did.

Hiking up to Herman Lake in the summer takes only about two hours. Our fastest time up was an hour and three-quarters last July. (More fit Coloradans somehow run the trail.) It takes considerably longer in the winter. A few weeks back it took three hours. In a few months, I'll make the climb on skis and the return trip down will be a hoot. Yesterday though, it was a slow slog up the hill. I should have taken a hint perhaps when the only two people I saw coming down the trail were both wearing crampons.

Hiking Herman Gulch has become a habit for the dog and me this year. We started in early May, with snow still in the woods and the Lake frozen solid. We've managed to make the trip about once a week since then. July brought us warm sunny days where we slept the afternoon away on a boulder that juts into the lake—not yesterday though.

This was the first time that we turned back short of our weekly goal. We could probably have made our way to the top of that last hill. Good chance we could also have made it down without injury. Yet it was a good choice to listen to the dog and turn back. In the risk versus benefit analysis, our decision was a no-brainer.

These days it is popular to set goals: five-year goals, ten-year goals, mission statements . . . These concepts have moved from of the province of organizations and corporations to individuals.

Closely defined goals make me nervous. This goes back to Portland when we were in school. While a student at NCNM, I was involved in ski patrol and mountain rescue groups that patrolled Mt. Hood. That mountain can be an easy, though long, climb up, and thousands of people make the summit each year. It is a straightforward ascent, but it is weather dependent. Too often people would succumb to “summit fever” and not have the sense to cancel a climb or turn back if the weather soured. It's easy to mistake a summit for a goal. Unfortunately this summit goal sometimes ended in tragedy. Perhaps that experience has left me extra sensitive to goal setting.

I started writing about Herman Gulch because I'm hoping to drag Michael Cronin up there. He'll be in Colorado in a few weeks and we have plans to visit Keystone, the site of the 2013 AANP conference. The Herman Gulch trail is on the way, so I'm hoping we can make the time for a bit of a hike. Depends on the weather obviously. Hopefully we'll have some pictures to share with all of you.

Notwithstanding my distrust of goal setting, I have been thinking about what our goals should be for the AANP conference next summer. Providing quality continuing education remains foremost and I'm hoping to in the process to define what good CE looks like.

How do we know what will be a good continuing education presentation? There is no doubt a mathematical formula that factors the speaking ability of the presenter with the amount of effort made in preparing the lecture that will predict attention span of the audience. Yet a totally tedious speaker would be tolerable if you come away having learned something. Thus content may be more important than presentation.

There is no shortage of new information that we need to keep up with. Over the past few conferences we have put more emphasis on lecture titles that include the word, update: oncology update, botanical update, gynecology update, etc. These lectures are necessary, as the practice of medicine is anything but stable, but also potentially tedious.

There are two things that we hope to find in lectures. First is whether a lecture changes the way we practice. Call this the Monday Question. Will you tell your patients something different the Monday after the conference after listening to this lecture? This second item is more elusive than the first. It is what we could call, “Paradigm Shifting.” Does this lecture fundamentally change the way we view an issue related to practice?

Some lectures may have value simply because they fit into the “Preaching to the Choir” category; they reaffirm things we already believe.

And then there is the Evidence Based Medicine (EBM) business. Certain quarters of our profession are lobbying for presentations that advance our knowledge and utilization of EBM. Those of you familiar with my contributions to the Natural Medicine Journal will know that I lean in that direction. Yet if all CE fell into this mode, we would miss something important that our conferences provide.

EBM speaks of the relative strength, or levels, of evidence. The strongest evidence is probably a meta-analysis of multiple randomized controlled trials (RCTs). On the opposite side of the continuum, though still a part of EBM, is Level III Evidence. This is defined as: opinions of respected authorities, based on clinical experience.

Our profession's clinical protocols are built on Level III evidence and most of our colleagues are not ready to abandon what we do until such time as there are RCTs to prove it. We still need to pay attention if a colleague can say, “Based on my quarter century in practice, I think this works,” even if she or he has no p-values. Perhaps instead of using the term Level III, we should substitute, “Wisdom of Our Elders.”

How best can we strike a balance to help move our practices toward this evidence-based model while at the same time preserving and passing on the wisdom of our more seasoned practitioners? Perhaps our speaker selection committee should score each abstract as to the source of the information. On one side of the continuum are randomized controlled trials (RCT score) and on the opposite side is Elder Wisdom (EW score). Ideally a speaker relies solely on neither but integrates the two together.

I started this blog by revealing my distrust for goal setting. Yet in writing this I have admitted to a singular goal, that is to continually raise the quality of education presented at the AANP conferences. This is the sort of goal one can't turn back from.