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Saturday, May 14, 2016

How to know if its science or consensus

I like the idea of best practice medicine. These are the recommendations or guidelines by which we live with when treating patients.  The problem with these is that many of the guidelines are based on consensus and not science.  This results in healthcare providers offering profligate or surreptitious treatment to our patients, and often with the side effect of frustration, burnout, and apathy.

If you know that what you are ordered to do is a complete waste of time and money, and you have no choice but to do as you are told in order to keep your job, chances are that you are well aware that medicine is not based on science but consensus.  As John described a while back, a consensus is not science.  If it comes to a vote, it's not science, it's a consensus. If it's believed because it's popular, it's not science.

Science is infiltrated with consensus.  So how do you know if it's science or consensus?  When you go to school, teachers must teach you the consensus view.  It's then up to you to form an opinion.  So how do you form opinions?  There are basically two ways.  When posed as a question, you can ask one of the following two questions.
  1. Does it feel good?
  2. Does it do any good?
So, let's pose a question.  You have a 72 year old male admitted to the emergency room with pink frothy secretions coming from his nose and mouth.  The doctor orders a bronchodilator.  
  1. Does it feel good?  Yes.  It makes me feel like I'm doing something to help this patient
  2. Does it do any good?  No.  All it does is add more fluid to the airways. 
You see. Now, let's pose question #2: You have a 48 year old man who is not in respiratory failure but is suffering from kidney failure. In order to prevent pulmonary edema from developing, the doctor orders intermittent BiPAP. 
  1. Does it feel good? Yes. I believe the increased intrathoracic pressure will assure that fluid is not forced out of pulmonary vessels. The increased pressure forces fluid that seeps out back into the vessels. Believing that it does this makes me feel good.
  2. Does it do any good? No. There is no science that shows that BiPAP in any way will prevent heart failure and pulmonary edema. 
Example #3:  Okay, so you have a patient with pneumonia. The doctor orders an albuterol breathing treatment. The patient feels no different after the treatment. The patient has crackles in the left base before and after the treatment. But the patient is admitted, and treatments are ordered every four hours. 
  1. Does it feel good? Yes. I believe that the albuterol will somehow cause the patient to cough up that pneumonia. It makes me feel good to know I'm doing something.
  2. Does it do good? No. The treatments do not make the patient feel better, so they are a waste of time. There is no science that shows albuterol goes into alveoli, let alone that it reduced inflammation in alveoli enough to fit in and join to beta adrenergic receptors that do not exist in alveoli. 
See what I mean. Science is not a consensus. If it's up to a vote, it's not science. If 99.9% of doctors believe albuterol cures pneumonia, that does not make it true. Science means that it either is or it is not. It does not matter what doctors think. Either albuterol treats pneumonia or it does not. See. 

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