Hem > Uncategorized > The whole truth and nothing but

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.

Kategorier:Uncategorized
  1. patrik
    april 14, 2012 kl. 1:46 e m

    I agree Katrin. It is very difficult to provide care with high quality. EBM is of course a cornerstone, but there is so many other factors to consider. So how should we do? What is important? How can we get better? This is a real challenge for us! / patrik

    • april 14, 2012 kl. 6:00 e m

      Of course we need to keep updated with the literature, but I also think we need to get involved in research ourselves, to better understand how to interpret it. Then we need to discuss how all this information is relevant to our practice and if it seems reasonable in the light of our own experiences. Working in other settings and countries provides excellent opportunities to understand how and why doctors do things differently.

  2. april 15, 2012 kl. 11:08 f m

    I’m all in favour of EBM; but, as you say, some people will focus in on some detail and not see the bigger picture. This is not good EBM.

    You risk a straw-man attack if you tar all EBM with the brush of inappropriately applied evidence.

  3. april 15, 2012 kl. 8:08 e m

    Hi Katrin
    great article! Medicine thankfully is not all about science and evidence based practice. There is an art to it. That is why all doctors swear an oath. I agree we should all try to do some research at some point. It helps improve what we do, if not the least by forcing us to understand evidence based principles.

    I met a Swedish female doctor last year at an aeromedical conference in Perth. She had moved her whole family to one of the most remote RFDS bases in Australia. If you seek some inspiration I would recommend her presentation on one of the most memorable days in her emergency medicine career with RFDS
    http://www.aeromedaustralasia.org/img.ashx?f=f&p=perth_2011%2fANDREWS+Ross_WIDING+Catarina+_Read-Only_.pdf

    what you learn and how you apply it intelligently can make a DIFFERENCE!
    If you ever want to come work for RFDS in Australia, you got a reference from me!

    keep the faith
    Minh

    • april 15, 2012 kl. 9:16 e m

      Thank you Minh for your wise words and generous offer. I love the challenge of working in different environments and learning new things so working in some remote place in Australia is definitely on the list. At the moment it is kind of hard to convince my family to move that far away, though.

    • april 15, 2012 kl. 9:17 e m

      PS. Great presentation, but hopefully not your everyday scenario.

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