I call them therapeutic fashions, things that we do because it's fashionable and popular. This week three of these were busted by...what else...the RCT
The bicarbonate examples hit home from the resuscitation side. We push amps of bicarb in a cardiac arrest because it feels like doing something against an ugly pH, and the trials keep saying return of circulation is no different than placebo. SODa-BIC and the arrest data are the uncomfortable mirror: the intervention that feels most physiologically obvious is the one we have examined least, because questioning it feels like questioning competence. Your equipoise point is really a cultural one, that certainty is the enemy of the trial we most need. The thing I would add from the floor is that reflexes like this get taught nurse to nurse and resident to resident, so they outlive the evidence that never supported them. Beyond running the trial, how do you actually unlearn a bedside reflex once a whole generation has already absorbed it as the standard of care?
Add to this list...triple H therapy for vasospasm after aneurysmal SAH...I spent 7 years of residency being chastised at 6am for not 'administering' proper triple H therapy to the aSAH patients at 2am....only to later discover it wasn't helpful and probably caused harm....
lets hear from the doctors working in the trenches what works for them. Of course we have both the doctor and the treatment . Ignoring doctors and going for ( rigged ) RCTs is the biggest problem in medicine , taking power away from doctors in the trenches to big pharma , hospitals , admin and doctors sitting on their boards
Can all these things be studied? Yes but some are really difficult to study.
Take the Swann-Ganz catheter. Physiologically speaking if it works it should work in patients with septic shock and cardiomyopathy. Septic shock is pretty rare and adding cardiac dysfunction to it makes it much rarer. For example the recent excellent TARTARE-2S trial. It was a negative trial of shock evaluation. However despite evaluating over 4,000 patients with sepsis only approximately 250 met enrollment criteria and of those many did not have cardiac dysfunction where shock evaluation is expected to help the most. So despite screening over 4,000 patients the study was still most likely underpowered.
in the Critical Care community treating our most sick patients is a little bit like treating patients with rare diseases - the most sick patients do indeed have a disease that probably affects less than one in a million. But worse than standard rare diseases we don't even have good definitions of the diseases we are treating, making it even more difficult to study them.
So is it possible to study interventions like the swan dance catheter.? If we actually choose the right group of patients to study it becomes nearly impossible to come up with a definition useful in a clinical trial. Even if we succeed in the first part it is still extremely difficult to enroll enough patients meeting that definition.
So we have to go back to physiological evaluation and clinical judgment both quite poor substitutes for RCTs
We truly have a hard time changing the way we do things in medicine. Partly due to the fear of missing something or causing more harm but also because as we progress in our career it is, for some, hard to learn or consider new things. Medicine is a life long learning career. The best point was to sit down, ask questions and listen to the response (while not always possible in a severe patient) it is always helpful in giving good care.
Great points, all. Two comments: many of these guideline driven interventions for management of severe sepsis (ie, salt water drowning within 3 hrs) become dogma because CMS, and consequently, private insurers, tie reimbursement to these practices. Once established, they are hard to change and it’s very difficult to withhold payment for doing something than not paying if something is not done. Second, I saw an order for “renal dose” dopamine in a patient last week in a large teaching hospital so we have a long way to go.
From week 1 of the evidence-based medicine course that I teach for nursing students: According to Melnyk and Fineout-Overholt (2023), The very first step of evidence-based practice is to "Develop a spirit of inquiry within an EBP culture and environment" (p. 19). Melnyk and Fineout-Overholt (2023) define a "spirit of inquiry... [as] a consistently questioning attitude toward practice so that clinicians are comfortable with and excited about asking questions regarding their patients' care as well as challenging current institutional or unit-based practices" (p. 19).
However, developing a spirit of inquiry and questioning practice is a hard sell. Overall, my students are very uncomfortable with questioning guidelines and established practices.
This harkens me back to the title of a previous SM editorial: “ should guidelines have an expiration date“.
The ultimate tragedy of guidelines is that the doctor and or the hospital get dinged for not following them.
This is emblematic of electronics/AI removing the scientific/compassionate thinking of a doc with a critically ill patient in front of him/her who may or may not fit the
The “sacred guidelines”.
As Einstein said in 1936: “when technology overtakes human interaction, we will have a generation of idiots.” I would simply add or “robots”.
Like the expert doc that came to court and when asked stated he was basing his opinion on the Merck Manual, and, 100% of people he did CPR on survived ….
Tackling Goodhart's Law one RCT at a time! Unfortunately, so much of our "progress" in medicine is in unlearning while the financial incentives reward the new mistakes (that will have to be unlearned at a later date)...
Excellent analysis. In Critical Care, I continuously emphasize to the residents and fellows that to know the literature and the "guidelines" is great but to remember that patients are individuals with nuance and not "populations".
The bicarbonate examples hit home from the resuscitation side. We push amps of bicarb in a cardiac arrest because it feels like doing something against an ugly pH, and the trials keep saying return of circulation is no different than placebo. SODa-BIC and the arrest data are the uncomfortable mirror: the intervention that feels most physiologically obvious is the one we have examined least, because questioning it feels like questioning competence. Your equipoise point is really a cultural one, that certainty is the enemy of the trial we most need. The thing I would add from the floor is that reflexes like this get taught nurse to nurse and resident to resident, so they outlive the evidence that never supported them. Beyond running the trial, how do you actually unlearn a bedside reflex once a whole generation has already absorbed it as the standard of care?
Another fantastic commentary.
Add to this list...triple H therapy for vasospasm after aneurysmal SAH...I spent 7 years of residency being chastised at 6am for not 'administering' proper triple H therapy to the aSAH patients at 2am....only to later discover it wasn't helpful and probably caused harm....
Most medical practice is dogma. I've been saying for 20 years that bicarb treats a number not the patient
lets hear from the doctors working in the trenches what works for them. Of course we have both the doctor and the treatment . Ignoring doctors and going for ( rigged ) RCTs is the biggest problem in medicine , taking power away from doctors in the trenches to big pharma , hospitals , admin and doctors sitting on their boards
Can all these things be studied? Yes but some are really difficult to study.
Take the Swann-Ganz catheter. Physiologically speaking if it works it should work in patients with septic shock and cardiomyopathy. Septic shock is pretty rare and adding cardiac dysfunction to it makes it much rarer. For example the recent excellent TARTARE-2S trial. It was a negative trial of shock evaluation. However despite evaluating over 4,000 patients with sepsis only approximately 250 met enrollment criteria and of those many did not have cardiac dysfunction where shock evaluation is expected to help the most. So despite screening over 4,000 patients the study was still most likely underpowered.
in the Critical Care community treating our most sick patients is a little bit like treating patients with rare diseases - the most sick patients do indeed have a disease that probably affects less than one in a million. But worse than standard rare diseases we don't even have good definitions of the diseases we are treating, making it even more difficult to study them.
So is it possible to study interventions like the swan dance catheter.? If we actually choose the right group of patients to study it becomes nearly impossible to come up with a definition useful in a clinical trial. Even if we succeed in the first part it is still extremely difficult to enroll enough patients meeting that definition.
So we have to go back to physiological evaluation and clinical judgment both quite poor substitutes for RCTs
These used to be standard of care when I trained in the 90s. Has medicine forgotten it’s common sense?
“Empathy, compassion, and sitting down when taking a history; these things require no trial. Almost everything else, randomize or later look foolish.“
My favorite part. ❤️
We truly have a hard time changing the way we do things in medicine. Partly due to the fear of missing something or causing more harm but also because as we progress in our career it is, for some, hard to learn or consider new things. Medicine is a life long learning career. The best point was to sit down, ask questions and listen to the response (while not always possible in a severe patient) it is always helpful in giving good care.
Great points, all. Two comments: many of these guideline driven interventions for management of severe sepsis (ie, salt water drowning within 3 hrs) become dogma because CMS, and consequently, private insurers, tie reimbursement to these practices. Once established, they are hard to change and it’s very difficult to withhold payment for doing something than not paying if something is not done. Second, I saw an order for “renal dose” dopamine in a patient last week in a large teaching hospital so we have a long way to go.
Remember optimizing the wedge at 17 for MI??
From week 1 of the evidence-based medicine course that I teach for nursing students: According to Melnyk and Fineout-Overholt (2023), The very first step of evidence-based practice is to "Develop a spirit of inquiry within an EBP culture and environment" (p. 19). Melnyk and Fineout-Overholt (2023) define a "spirit of inquiry... [as] a consistently questioning attitude toward practice so that clinicians are comfortable with and excited about asking questions regarding their patients' care as well as challenging current institutional or unit-based practices" (p. 19).
However, developing a spirit of inquiry and questioning practice is a hard sell. Overall, my students are very uncomfortable with questioning guidelines and established practices.
This harkens me back to the title of a previous SM editorial: “ should guidelines have an expiration date“.
The ultimate tragedy of guidelines is that the doctor and or the hospital get dinged for not following them.
This is emblematic of electronics/AI removing the scientific/compassionate thinking of a doc with a critically ill patient in front of him/her who may or may not fit the
The “sacred guidelines”.
As Einstein said in 1936: “when technology overtakes human interaction, we will have a generation of idiots.” I would simply add or “robots”.
A facet of this issue left unmentioned is medicolegal liability.
The vultures are always ready to pounce and lay juries can be easily misled.
Jurors can’t follow discussions about hydrogen ion, hemoglobin, and hypercarbia.
But they are susceptible to “A pH of 7.35 is good and 6.9 is bad. Why didn’t you fix it, doctor?”
It’s supposed to be a jury of your peers …
😂🙄
Like the expert doc that came to court and when asked stated he was basing his opinion on the Merck Manual, and, 100% of people he did CPR on survived ….
Tackling Goodhart's Law one RCT at a time! Unfortunately, so much of our "progress" in medicine is in unlearning while the financial incentives reward the new mistakes (that will have to be unlearned at a later date)...
Excellent analysis. In Critical Care, I continuously emphasize to the residents and fellows that to know the literature and the "guidelines" is great but to remember that patients are individuals with nuance and not "populations".
Remember the old saw: “We know that 50% of what we currently believe in medicine is wrong. The problem is that we don’t know which 50% it is.”