Entry 2

Today was an eventful day. It was a mixture of clinical exposure and teaching.

In the morning, I saw a few patients in the TB clinic. The staff and admin assistants were very kind in orienting me to the clinic. Not surprisingly, I felt quite nervous before knocking on the door of the room of my first patient. I mentally prayed that what I’d read last night would prove useful in just a few moments… I needn’t have worried. My patient was very pleasant, and I found myself rattling off questions about TB risk factors and clinical features with ease. When reviewing the case with my staff, I had formulated an assessment which included a false positive Mantoux at the top of my differential. My staff agreed with my assessment, boosting my confidence further and bringing a smile to my face as I headed to noon rounds.

The topic at rounds was a sharp deviation from the usual clinical scenario. It was evidence-based medicine and one of the staff presented a new controversial paper examining non-inferiority of edoxaban to LMWH’s in preventing and treating VTE among cancer patients. My first instinct was disbelief. After all, hadn’t I been taught in medical school that LMWH’s showed well-established mortality in precisely this population? Surprisingly, the study did show non-inferiority of the NOACs compared to LMWH’s for VTE treatment at roughly the 90-day mark. After this period, the results diverged. Concurrently, the incidents of major bleeding in the NOACs arm was higher than the LMWH arm right from the beginning. However, due to the ambiguity in some of the design details, it leaves the rationale why open to interpretation. I left rounds thinking to myself that as a future physician, I want the paper's results to be further verified to ensure patient safety and better care quality. Yet, if I were a cancer patient, would I not prefer to take a pill once a day rather than having to stab my abdomen with a needle? I reasoned that the study outcomes would have to be replicated and the standard knowledge-translation window would have to elapse before this commonplace practice changed. Until then, cancer patients would have to continue to endure daily painful injections. It was food for thought.
- AX.