The whole truth and nothing but

I have started to write this post several times, but I never managed to finish it. I guess I’m just afraid it will come out wrong. But I still feel I have to give it a try.When I started to practice emergency medicine in Sweden there wasn’t any structured training or good role models. I was thrilled to find all these great EM podcasts and would listen to everything I could possibly find. That also got me interested in the EM literature, which no one in Sweden seemed to follow. One could even say that this is how I was introduced to evidenced based medicine. Of course I had heard about EBM before, but it is not a term we use in our daily practice. Most doctors don’t read journals more than occasionally, unless they are into research.

Anyway, my encounter with all this information about how emergency medicine was being practiced in other countries, made me more and more convinced that we weren’t getting it right in Sweden. That impression has changed over the last year, in a way that makes me scared to go and work abroad again.
After meeting with and working with doctors who were trained in more evidenced based systems, I was disappointed. I found it to be a battle of who had read the most and the latest journals and very little of discussion about what was right for the actual patient. The doctor who could cite a publication that no one else had read, would end the discussion in victory. Any suggestion was met with a demand for evidence. As if every question had one, and only one, correct answer. And that answer was to be found in a book or a journal.

So now when I listen to Scott Weingart debate Minh Le Cong whether needle or knife is better for a cricothyrotomy, I don’t enjoy it the way I used to. Of course the debate is a great way to show the advantages and disadvantages with respective technique. But in the end, no matter what high quality studies they present, I would always trust either one of them to use the technique they feel more comfortable with. The best technique in a given situation depends on the patient, the doctor’s training and experience and all the other circumstances. The reason why things go wrong are rarely that you hadn’t read the latest publication. And reading every journal there is won’t make you a better doctor, unless you put a great deal of effort into considering how this is relevant to your practice. Before I assumed that everybody share that understanding with me, but now I’m not so sure. (I still believe that Scott and Minh do, though.)

The human body is extremely complicated, and our knowledge is limited. Evidenced base medicine is the foundation of that knowledge, but it does not represent the whole truth. There is, for example, good evidence to support the use of ACE inhibitors in congestive heart failure. But there is, on the other hand, excellent evidence to prove that an ACE inhibitor was the wrong treatment for the CHF patient who died from angioedema. This may seem obvious, but I believe it is often forgotten that just because we did the best we knew how, it doesn’t necessarily mean we did right. The question about what the evidence based treatment is, has only one correct answer. (An answer that interestingly enough changes over time.) But our main objective shouldn’t be to practice EBM. It should be to give our patients the best treatment possible. EBM is just a means and adherence to evidence based protocols is just a surrogate marker.

Focusing on one thing only, will make us lose the bigger picture. The cardiac interventionist who put in two drug eluting stents in the old man with a STEMI might have read all the latest publications. He might even be a world famous authority in his field. But since he didn’t bother to take a good history, he didn’t predict that those diverticles that had bled twice before when the patient was on aspirin, were now bleeding on aspirin and clopidogrel, with a high risk of in-stent thrombosis if this treatment were discontinued. Medicine has to make sense. Evidence based medicin is an excellent base, but it always needs a topping of good doctoring.