Nonbeliever...

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BAM!

BAM!

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I've been having a hard time believing in medicine recently. Sure I see the utility in repairing a laceration, giving some antibiotics, or taking out an inflamed appendix. But the other stuff. Like anticoagulation for DVT or acute coronary syndromes. PPIs for GI bleeds. The sorts of things that are standard of care, but don't add any measurable benefit. May even add some harm. I'm having trouble reconciling the fact that I am giving these medications to patients because it's the standard of care. Yet I don't believe in them. I know lots of doctors do, but I'm not one of them. Do any of you tell your patients that anticoagulation doesn't help, but we do it because of theory and tradition-driven guidelines? Do I just wait until the guidelines change like it did for steroids in spinal cord trauma? Does anyone else feel this way? Does anyone care?

I feel like I'm looking out for myself (malpractice), often at the expense of the patient.
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Your screen name should really be "BAN!"
 
i'm actually being serious.
 
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I know how you feel. In conjunction with the neurologist, I killed a patient with TPA once. Perfect candidate for it. Onset of stroke to neurologist at bedside was 15 minutes and med was going within 30. Not door time. Onset time. NIHSS ~15 as I recall. No contraindications.

I'm appalled that our NNTs for our standard therapies are so high when you really measure them. It's frustrating to me how poor our medical knowledge and our expensive tests are at working up female abdominal pain, both acute and chronic.
 
BAM! said:
I've been having a hard time believing in medicine recently. Sure I see the utility in repairing a laceration, giving some antibiotics, or taking out an inflamed appendix. But the other stuff. Like anticoagulation for DVT or acute coronary syndromes. PPIs for GI bleeds. The sorts of things that are standard of care, but don't add any measurable benefit. May even add some harm. I'm having trouble reconciling the fact that I am giving these medications to patients because Tis the standard of care. Yet I don't believe in them. I know lots of doctors do, but I'm not one of them. Do any of you tell your patients that anticoagulation doesn't help, but we do it because of theory and tradition-driven guidelines? Do I just wait until the guidelines change like it did for steroids in spinal cord trauma? Does anyone else feel this way? Does anyone care?

I feel like I'm looking out for myself (malpractice), often at the expense of the patient.
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Important question, before I answer yours. What stage are you at? Resident, student, attending?
 
BAM! said:
I've been having a hard time believing in medicine recently. Sure I see the utility in repairing a laceration, giving some antibiotics, or taking out an inflamed appendix. But the other stuff. Like anticoagulation for DVT or acute coronary syndromes. PPIs for GI bleeds. The sorts of things that are standard of care, but don't add any measurable benefit. May even add some harm. I'm having trouble reconciling the fact that I am giving these medications to patients because Tis the standard of care. Yet I don't believe in them. I know lots of doctors do, but I'm not one of them. Do any of you tell your patients that anticoagulation doesn't help, but we do it because of theory and tradition-driven guidelines? Do I just wait until the guidelines change like it did for steroids in spinal cord trauma? Does anyone else feel this way? Does anyone care?

I feel like I'm looking out for myself (malpractice), often at the expense of the patient.
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Yep. The longer I practice, the less I believe in anything but saline, steel, aspirin and electricity. How do I keep going without getting sued into oblivion? I pick my battles and I empower my patients to decline ineffective interventions with shared decision making.
 
Birdstrike -- Attending.

I try to implement shared decision making too. But certain patient populations have a difficult time with this and want the doctor to make decisions for them. In these cases I feel a guilty when I go with the standard of care, order expensive and dangerous diagnostics and therapies to CYA. Especially if they are cash paying.

WCI thanks for sharing your story.
 
BAM! said:
Birdstrike -- Attending.

I try to implement shared decision making too. But certain patient populations have a difficult time with this and want the doctor to make decisions for them. In these cases I feel a guilty when I go with the standard of care, order expensive and dangerous diagnostics and therapies to CYA. Especially if they are cash paying.

WCI thanks for sharing your story.
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Yeah, that happens too. When they put the ball back in my court I'll usually say something like "If you were my [wife/mother/whatever] I'd say that we should just watch and wait. If [x,y,z] develops then come back and we'll reconsider." After documenting that in the chart, I feel very comfortable with my risk exposure.

In cases where patients still "want it all" and for me to refuse would be to go against the standard of care, I acquiesce. It doesn't bother me as much anymore. I view it as being in the same category as COPD'ers who continue to smoke, diabetics who continue to drink Coke, etc. It's their body, and they get to do with it what they want.

I realize that you know all this, and I'm not trying to be patronizing - I'm just saying what works for me.
 
BAM! said:
I've been having a hard time believing in medicine recently. Sure I see the utility in repairing a laceration, giving some antibiotics, or taking out an inflamed appendix. But the other stuff. Like anticoagulation for DVT or acute coronary syndromes. PPIs for GI bleeds. The sorts of things that are standard of care, but don't add any measurable benefit. May even add some harm. I'm having trouble reconciling the fact that I am giving these medications to patients because Tis the standard of care. Yet I don't believe in them. I know lots of doctors do, but I'm not one of them. Do any of you tell your patients that anticoagulation doesn't help, but we do it because of theory and tradition-driven guidelines? Do I just wait until the guidelines change like it did for steroids in spinal cord trauma? Does anyone else feel this way? Does anyone care?

I feel like I'm looking out for myself (malpractice), often at the expense of the patient.
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Yes, others feel this way.

Yes, plenty care, and are torn.

One of the most memorable things I remember from medical school, was a pediatrics professor telling us,

"A third of what you learn, you'll forget. A third will turn out to be completely wrong. A third will turn out to be right. And a there's no way to know right now, which third is which." (I added the last line).

So yes, much of what we do may turn out to be wrong. You and I may feel sure which those things are but we can never be sure. I try to accept the fact that I'm a good person, in an imperfect system, trying to help my patients to the extent I can.

As far as having doubts about certain standards of care, possibly being harmful. You may be right, or you may be wrong. However, I've reconciled that with the fact that the "standard of care" is determined by a legal system set up, by the people (your and my patients) and therefore there's a shared responsibility. As much as we doctors (http://www.epmonthly.com/whitecoat/2012/08/a-nameless-faceless-killer/) have tried to get the word out that defensive medicine is harmful, the masses choose to maintain the status quo through their votes at the ballot box. So it's a shared burden. It's not all on your shoulders. If it was up to you, you'd scrap the medical malpractice setting we have so that you can take better care of your patients. But you can't by yourself. This is much bigger than you and I.

Take solace in the fact that you,

1-Are doing the best you can to help your patients, in an imperfect system that makes it hard on both you and them, and

2-Have patients that are lucky enough to have a doctor that cares.



Happy Holidays, to all.
 
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As long as Americans continue to insist on having a health care system which lets managers rush doctors for profit and lets patients sue doctors for proft they will get exactly what they ask for.
 
I don't believe in many of the interventions we do. Our workups and treatment for DVT/PE are absurd. Thrombolytics for CVA, hypothermia for cardiac arrest, antibiotics for most things. All of these are either nonsense, or of such poor therapeutic value that it's laughable. I will continue to do everyone of these things. Why? Because it's less effort and energy for me to fight against the system. I want to do the minimum amount of work, make my shift as easy as possible, then collect my check and go home. That's it.
 
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GeneralVeers said:
I don't believe in many of the interventions we do. Our workups and treatment for DVT/PE are absurd. Thrombolytics for CVA, hypothermia for cardiac arrest, antibiotics for most things. All of these are either nonsense, or of such poor therapeutic value that Tis laughable. I will continue to do everyone of these things. Why? Because Tis less effort and energy for me to fight against the system. I want to do the minimum amount of work, make my shift as easy as possible, then collect my check and go home. That's it.
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General Veers-By far the most blisteringly honest person on SDN EM.
 
WilcoWorld said:
Yep. The longer I practice, the less I believe in anything but saline, steel, aspirin and electricity. How do I keep going without getting sued into oblivion? I pick my battles and I empower my patients to decline ineffective interventions with shared decision making.
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You'll stop believing in saline before the end of the next decade. Nothing normal about it. I use it for head injuries (and not because it's saline, but because it's hypertonic sodium), and when I need to give Rocephin, because the FDA says I can't mix it with LR. Everyone else gets LR. Even kids.
Steel will still apply to a lot of things, but look at how they're treating appys with just Abx in Europe. Then look at the studies showing no difference in outcomes with and without Abx in diverticulitis. We do quite a few things because "we've always done it that way." And when you try and change things, there are people who treat it as if you're killing their god. Just look at sterile technique with lacerations, or epi in digits. Plenty of attendings still yell at residents for doing this, even the week after we went over it in conference.

God grant me the serenity to accept the things I cannot change;
courage to change the things I can;
and wisdom to know the difference.

PS. Aspirin isn't effective for people born on Tuesdays. At least, that's what subgroup analyses tell us. It's the same logic used to promote tPA, so we might as well follow that too.
 
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Dr.McNinja said:
Aspirin isn't effective for people born on Tuesdays. At least, that's what subgroup analyses tell us. Tis the same logic used to promote tPA, so we might as well follow that too.
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What if they're born in the first 4.5 hours of a Tuesday, and we include discharge on a Wednesday as part of our composite outcome?
 
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thanks for the replies! GeneralVeers, you are ridiculous and hillarious!
 
Look there are lots of studies giving contradictory information. I see my job as to assimilate studies as best as possible, provide information to patients and give them the best chance at the best possible outcome.

Does because a study in the 60's on using heparin for DVT's was no better than ASA mean heparin (or warfarin), doesn't reduce the risk of recurrent VTE? The answer to that is probably no.

Related data, but not quite the same is how long to anti-coagulate for unprovoked DVT: Kearon C et al NEJM 1999. Basically there was a statistically significant reduction in VTE for patients with prolonged anti-coagulation; 17/83 placebo (11 DVT's 5 non-fatal PE's and 1 fatal PE), and 1/79 coumadin (1 non-fatal PE, which occurred after discontinuation of coumadin 14 months early but is included 2/2 intention to treat analysis). Would it be reasonable to believe that warfarin worked better than placebo in the first three months of anticoagulation: probably, but no one is going to do that study.

Also, there is no data on using vasopressors vs. placebo (plenty comparing different types). Does this mean we should stop using them because a RCT hasn't been done? How many times have I stopped vasopressors on a patient because the family wanted to withdraw and the patient died immediately thereafter. Vasopressors are a bridge to recovery, like so many other interventions.

The way I see it is read the studies, and shape your practice in a way that you can feel comfortable modifying things. Also, always take the time to think before ordering any treatment for a patient from placing an IV to a bag of Normosol. Don't believe every skeptic who says things absolutely do not work, or jump on the bandwagon of the guy/gal who stands up at a podium and says that X intervention saves lives.

Also I try and take a lesson from the family medicine doctors every now and again, who know that sometimes just being nice, empathetic and reassuring is as important to the patient and their family as the 1700 studies performed on how to best treat a patient with an acute CVA.
 
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ORL10 said:
Look there are lots of studies giving contradictory information. I see my job as to assimilate studies as best as possible, provide information to patients and give them the best chance at the best possible outcome.

Does because a study in the 60's on using heparin for DVT's was no better than ASA mean heparin (or warfarin), doesn't reduce the risk of recurrent VTE? The answer to that is probably no.

Related data, but not quite the same is how long to anti-coagulate for unprovoked DVT: Kearon C et al NEJM 1999. Basically there was a statistically significant reduction in VTE for patients with prolonged anti-coagulation; 17/83 placebo (11 DVT's 5 non-fatal PE's and 1 fatal PE), and 1/79 coumadin (1 non-fatal PE, which occurred after discontinuation of coumadin 14 months early but is included 2/2 intention to treat analysis). Would it be reasonable to believe that warfarin worked better than placebo in the first three months of anticoagulation: probably, but no one is going to do that study.

Also, there is no data on using vasopressors vs. placebo (plenty comparing different types). Does this mean we should stop using them because a RCT hasn't been done? How many times have I stopped vasopressors on a patient because the family wanted to withdraw and the patient died immediately thereafter. Vasopressors are a bridge to recovery, like so many other interventions.

The way I see it is read the studies, and shape your practice in a way that you can feel comfortable modifying things. Also, always take the time to think before ordering any treatment for a patient from placing an IV to a bag of Normosol. Don't believe every skeptic who says things absolutely do not work, or jump on the bandwagon of the guy/gal who stands up at a podium and says that X intervention saves lives.

Also I try and take a lesson from the family medicine doctors every now and again, who know that sometimes just being nice, empathetic and reassuring is as important to the patient and their family as the 1700 studies performed on how to best treat a patient with an acute CVA.
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I have no problem accepting that what we is not an exact science, either. What I have a problem with, is the fact that we crucify peers, defendants, skeptics or anyone based on so called "standards" of care that are more often than not, very shaky. The egocrats in medicine and law are so full of themselves and their own "standards," combined with distorted profit driven industry influence, the whole foundation really needs to be questioned.

If what we do as physicians is never perfect, exact and is based on ever changing, morphing standards of care that may not even be correct to begin with, let's treat ourselves that way, and set up a system of tort that treats us that way. But no, we have an industry of ego-God leaders we elevate, fawn over, and are afraid to question, strive for perfection and are judged under a system based on "reasonable physicians following the standard of care" which is often shaky, changing, uncertain or potentially incorrect in many cases. Like General Veers says, do the best you can and collect your check.


"Nobody told me there'd be days like these, strange days indeed -- most peculiar, mama"
-John Lennon
 
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GeneralVeers said:
I don't believe in many of the interventions we do. Our workups and treatment for DVT/PE are absurd. Thrombolytics for CVA, hypothermia for cardiac arrest, antibiotics for most things. All of these are either nonsense, or of such poor therapeutic value that it's laughable. I will continue to do everyone of these things. Why? Because it's less effort and energy for me to fight against the system. I want to do the minimum amount of work, make my shift as easy as possible, then collect my check and go home. That's it.
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More and more, I am focusing less on the systems flaws, and just hoping the Medicare/private-insurance gravy train will continue long enough that I can support my family and secure a comfortable retirement in an acceptable time frame. Fingers crossed.
 
Birdstrike said:
More and more, I am focusing less on the systems flaws, and just hoping the Medicare/private-insurance gravy train will continue long enough that I can support my family and secure a comfortable retirement in an acceptable time frame. Fingers crossed.
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You're closer to that timepoint than I am.
 
Birdstrike said:
More and more, I am focusing less on the systems flaws, and just hoping the Medicare/private-insurance gravy train will continue long enough that I can support my family and secure a comfortable retirement in an acceptable time frame. Fingers crossed.
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I'm a pragmatist. The system has been hijacked by nurses, bureaucrats, politicians, JCAHO and CMS all because doctors didn't want to be bothered with the administrative/legislative side of the business. Now that these non-physician entities have all the power they are never going to give it back. We are all powerless cogs in the giant machine. Given that fact it's easier to go with the current than against it. Like Birdstrike I too hope the gravy train continues at least for a few more years.....long enough for me to save up "F U" money and do whatever I want.
 
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