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
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”.
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".
Great column! My initial reaction was that all procedures should be subjected to RTCs. But are there procedures that cannot be evaluated this way? If so, what are their features? I also keep wondering why insurers pay doctors for delivering treatments whose efficacy is unproven. When they stop paying, doctors' practices will turn on a dime.
I once read that it takes 20 years for practitioners to catch up to the research. Part of this problem, I believe, is that what we learn in school (at least speaking from a nursing perspective) is gospel. The information is presented as facts that are not to be disputed. My 92 year old mother still brings up that in her day (the 1950's - she retired in 1959 from nursing) they did such and such and it was a good thing.
It takes an open mind and willingness to be constantly educated to look at the new research and apply it.
BTW, I remember that close to 20 years ago the ACLS standard for giving bicarb was removed and left to the judgement of the practitioner. Apparently they are still "judging" it to be useful. Sigh.
I feel like I am always on the other side of cardiologists who want to treat high LDL in older patients without atherosclerosis. What is the best way to make the argument? Patients get confused…
We need to get the Quality Metrics out of the picture and allow us to individualize treatment and use clinical judgement as a first step. BP and LDL goals are a good place to start.
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 …
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.”
Great column! My initial reaction was that all procedures should be subjected to RTCs. But are there procedures that cannot be evaluated this way? If so, what are their features? I also keep wondering why insurers pay doctors for delivering treatments whose efficacy is unproven. When they stop paying, doctors' practices will turn on a dime.
I once read that it takes 20 years for practitioners to catch up to the research. Part of this problem, I believe, is that what we learn in school (at least speaking from a nursing perspective) is gospel. The information is presented as facts that are not to be disputed. My 92 year old mother still brings up that in her day (the 1950's - she retired in 1959 from nursing) they did such and such and it was a good thing.
It takes an open mind and willingness to be constantly educated to look at the new research and apply it.
BTW, I remember that close to 20 years ago the ACLS standard for giving bicarb was removed and left to the judgement of the practitioner. Apparently they are still "judging" it to be useful. Sigh.
I feel like I am always on the other side of cardiologists who want to treat high LDL in older patients without atherosclerosis. What is the best way to make the argument? Patients get confused…
We need to get the Quality Metrics out of the picture and allow us to individualize treatment and use clinical judgement as a first step. BP and LDL goals are a good place to start.
A very dear and wise man always said “ The patient died in electrolyte balance “