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. 

Medicine based on consensus, not science

Medicine is an art based on science.  Much of medicine is based on flawed science. Or, as Richard Feynman once said, science is the belief in the ignorance of experts. 

Much of science is not even science: it's consensus.  It's basically the world's leading experts voting on what they think is fact, rather than waiting for the evidence to reveal the truth.  It's creating theories and voting on which ones should be in the forefront of our minds.  So when deciding on what to believe, we must never forget that "science is about evidence, not consensus."  

It is so hard in the medical profession to separate consensus from science.  In fact, one of the things that fascinated me most about the medical profession is it's loose relationship with science.  In fact, early on in my studies I learned that medicine is loosely based on science, and more so based on consensus, which is not science at all. 

Look at the hypoxic drive theory.  It was based on a study of four COPD patients, and became a gold standard based on a presentation by EJM Campbell to pulmonologists in 1960 about the results of a study based on only four COPD patients.  So basically the hypoxic drive theory, or hoax as I like to call it, was based on a consensus of experts, and had nothing to do with science. 

So basically physician's under oxygenated their patients for over 70 years, and many still do, based on a consensus.

Look at all the breathing treatments we give based on a consensus that albuterol cures every lung ailment you can think of. Our new healthcare law insists that a lung patient must be sick enough to need 3 breathing treatments for reimbursement criteria to be met. This includes COPD, CHF, Asthma, Pneumonia, etc. So 3 breathing treatments are ordered on all these patients, and it's assumed they are needed. What's wrong with this picture? It certainly has nothing to do with science. 

Other examples of consensus over science include:

• BiPAP pushes fluid out of lungs
• The earth is flat
• Man made global warming
• The continents cannot drift
• Stress causes ulcers
• Asthma is one of the seven pychosomatic disorders
• Phlogiston was necessary for combustion to take place

All of these theories are, or were, so widespread, and so well accepted, that they caused people to focus on treatments and therapies that probably did more harm than good (like under oxygenating COPD patients). As in the case with asthma, consensus caused experts to focus so much on a dead end path that it prevented the advancement of knowledge to the detriment of those who suffered from it (i.e., experts focused on treating asthma with psychosomatic medicines when they should have been looking treatments for inflammation and bronchospasm). 

So when you're thinking about whether or not you want to believe something is true, consider the evidence and not the consensus.  The fact that a majority of people believe something to be true does not make it so. In other words, it's okay to oppose the majority opinion, so long as the evidence is on your side. 

When a doctor orders something, it's your job as a therapist, or a nurse, to do as you are instructed.  For instance, if a doctor orders you to give a breathing treatment, then you must give it regardless that you know it is a waste of time.  As the old saying goes, "It can't hurt." 

Still, it really does hurt, because you're putting medicine into someone that doesn't need to be there, and, even though we can't always see them, all medicines come with side effects.  And then there's also the side effect of second hand ventolin on those who are doling it out all day long.

However, when a doctor orders for you to maintain an SpO2 in the low 80s because of the hypoxic drive myth, it's time to rise up and challenge the consensus for the benefit of the patient, because, Lord knows, oxygen is beneficial to the living heart. Thankfully the hypoxic drive consensus/hoax is slowly fading, and COPD patients are actually being oxygenated these days. 

Further reading.

• Rush Limbaugh: Peer Reviewed Science Exposed as Fraud
• NY TIMES:  Many Psychology Findings Not As Strong As Claimed, Study Says
• Wall Street Journal: Science is About Evidence, Not Consensus
• RT Cave: Second Hand Albuterol