Friday, January 28, 2005

M&M: Medical Myths.

To those who do not know, the ACGME is limiting the amount of work a resident can do at one time. The work remains the same though, so it has to be distributed to other residents. Residents used to have a culture of caring for patients and caring the their own excellence, because although they might not have known as much medicine as the attendings, their devotion and hard work gave them the utmost of respect from everyone in the hospital.

One time when I was an intern I fell asleep at 4 AM in a patient lounge and woke up to find that not only had the night-time janitor covered me in a blanket he'd gotten from a room on another hall, but he'd set up a cup of coffee with a note telling me that I'd better drink it. Nice guy.

These days the residents have it easier. Now there are many reasons that the new system is shit. One is that all the other doctors need to do more work, and don't like it. One is the fact that there is no bragging rights when you have to go home early. But the senior doctors put out bad arguments, like: "interns these days don't get to see the outcomes of what happens to their patients, so they don't learn anything." To those doctors, I have this to say.

You know what has to be the biggest medical myth other than telling undergrads that being a doctor is great because you get to take care of people (nurses do that)? It is this entire idea of possibly learning ANYTHING about patient outcomes from continuity of care.

Take cards. PVCs are bad. Lets give heart attack patients lidocaine to stop the PVCs they always get - that'll make them better because less PVCs (bad) are better. And it worked: less PVCs. So everyone is giving their patients lidocaine with their MIs, and they have less PVCs.

But problem: someone follows something called the scientific method, only recently applied to our field of medicine and does something called an experiment. He looks at tons of patients and finds that although many individual patients do well with or without lidocaine, there are more in the lidocaine group that die - without PVCs.

So that's been done over and over, proving that aspirin is good for MIs and lidocain is not. And ALSO proving that doctors are blind to outcomes unless they are heading up big trials with big numbers.

I would also add that its probably dangerous to think that by observing outcomes one can learn anything while on the floor. Some of the patients on lidocaine do really really well. Just like some of the people with leaches do really really well.

In the haze of what we do, we miss the big numbers from which you can get significance and meaning. Probably 90% of what we do has no basis in science, we just infer it does because we think we know some physiology.

Continuity of care: nonsense. Its a myth designed by really smart people to make residents feel bad when we go home after call. And idiots believe it. I say, there is no spoon. Signing out, Doc NOS


Blogger Sally said...

I think it's a really good thing that residents' hours are being limited. I know that as recently as a decade ago interns worked an average of 70 hours a week - and it makes me wonder how people in a chronically sleep-deprived state are supposed to make informed medical judgments and decisions. Seems to be the most obvious OH&S consideration.

3:31 PM  

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