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Editorials

Last 50 Editorials

(Click on title to be directed to posting, most recent listed first)

More Medical Science and Less Advertising
The Need for Improved ICU Severity Scoring
A Labor Day Warning
Keep Your Politics Out of My Practice
The Highest Paid Clerk
The VA Mission Act: Funding to Fail?
What the Supreme Court Ruling on Binding Arbitration May Mean to
   Healthcare 
Kiss Up, Kick Down in Medicine 
What Does Shulkin’s Firing Mean for the VA? 
Guns, Suicide, COPD and Sleep
The Dangerous Airway: Reframing Airway Management in the Critically Ill 
Linking Performance Incentives to Ethical Practice 
Brenda Fitzgerald, Conflict of Interest and Physician Leadership 
Seven Words You Can Never Say at HHS
Equitable Peer Review and the National Practitioner Data Bank 
Fake News in Healthcare 
Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad
   Leadership 
Disclosures for All 
Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to
Require Sleep Apnea Testing in Commercial Transportation Operators
The Unspoken Challenges to the Profession of Medicine
EMR Fines Test Trump Administration’s Opposition to Bureaucracy 
Breaking the Guidelines for Better Care 
Worst Places to Practice Medicine 
Pain Scales and the Opioid Crisis 
In Defense of Eminence-Based Medicine 
Screening for Obstructive Sleep Apnea in the Transportation Industry—
   The Time is Now 
Mitigating the “Life-Sucking” Power of the Electronic Health Record 
Has the VA Become a White Elephant? 
The Most Influential People in Healthcare 
Remembering the 100,000 Lives Campaign 
The Evil That Men Do-An Open Letter to President Obama 
Using the EMR for Better Patient Care 
State of the VA
Kaiser Plans to Open "New" Medical School 
CMS Penalizes 758 Hospitals For Safety Incidents 
Honoring Our Nation's Veterans 
Capture Market Share, Raise Prices 
Guns and Sleep 
Is It Time for a National Tort Reform? 
Time for the VA to Clean Up Its Act 
Eliminating Mistakes In Managing Coccidioidomycosis 
A Tale of Two News Reports 
The Hands of a Healer 
The Fabulous Fours! Annual Report from the Editor 
A Veterans Day Editorial: Change at the VA? 
A Failure of Oversight at the VA 
IOM Releases Report on Graduate Medical Education 
Mild Obstructive Sleep Apnea: Beyond the AHI 
Multidisciplinary Discussion (MDD) in Interstitial Lung Disease; Some
   Reflections 
VA Administrators Breathe a Sigh of Relief 
VA Scandal Widens

 

For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care welcomes submission of editorials on journal content or issues relevant to the pulmonary, critical care or sleep medicine.

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Saturday
Jun172017

EMR Fines Test Trump Administration’s Opposition to Bureaucracy 

Earlier this week the Health and Human Services Office of Inspector General (OIG) released an audit report on $6.1 billion paid to 250,000 clinicians in the incentive program for meaningful use of electronic medical records (EMRs) (1). A random sample of 100 clinicians who had received at least one incentive payment revealed that 14 of them who had had not met all meaningful use requirements as they had attested (Table 1) (1,2).

Table 1. Meaningful use deficiencies identified in 14 of 100 clinicians.

  • Six clinicians couldn't provide a mandatory analysis of security risks;
  • Four clinicians couldn't prove that they had generated at least one list of patients-another requirement -who had the same condition;
  • Three clinicians could not provide patient encounter data to document that they had met various meaningful use measures;
  • One clinician had 90-days' worth of patient encounter data when a year's worth was needed;
  • One clinician did not use certified EHR technology as much as required.

The OIG recommended that the Center for Medicare and Medicaid Services recover the $291,222 paid to the clinicians in the sample group and extrapolated the recovery to $729 million from the remaining clinicians based on this random sample. This is about 13% of the incentives paid to clinicians for the CMS EMR program. The decision to carry out the recommendation will ultimately fall to a US Department of Health and Human Services (HHS) secretary, Tom Price MD, who has opposed government programs that created regulatory hassles for physicians.

"We would protest if they went through with this," said Robert Tennant, director of health information technology policy at the Medical Group Management Association (MGMA). "Going after folks who tried to meet arbitrary government requirements, who made a good faith effort, isn't fair” (2). Tennant said that this complexity, made worse by evolving requirements, helps explain the deficiencies listed in the OIG audit. "I'm not surprised some providers found it daunting to keep up with the changes," he said. The requirement for a security risk analysis is a problem, Tennant noted, because CMS hasn't given clinicians sufficient guidance on how to meet the requirements. "This is a real stumbling block for smaller practices," he said. "They're not security experts, they're clinicians" (2). American College of Physicians Vice President of Governmental Affairs and Medical Practice Shari Erickson said that clinicians who originally attested to meaningful use lacked clear, specific guidance on what documentation they needed for each requirement (2).

CMS incentivized using EMRs because many clinicians were reluctant to initiate EMRs in their practices because of cost and efficiency considerations. Average costs to initiate an EMR were $163r,765 for a single practitioner and $233,298 for a practice with five physicians (3). Reimbursement under the EMR program was about $65,000 per provider (4). Furthermore, there was an 8% decrease in productivity after EMR initiation (3). In other words, if physicians wanted to see Medicare/Medicaid patients they were asked to use EMRs that cost them money and made them work harder.

The violations identified in the OIG audit seem fairly minor and are the type of trivial violations that the lawyers and bureaucrats seem to delight in identifying and excessively penalizing clinicians. In contrast, large health care organizations seem to go unpunished for more egregious violations. Witness the lack of action against Banner Healthcare for compromising 3.7 million medical records in 2016 (5). The average cost of data breach has been estimated at $398 per compromised record (2). Extrapolating, Banner should be fined nearly $1.5 billion.

Medicine is likely the most regulated industry in the US. Several of my colleagues have complained that the regulation seems more directed at them and not at the hospitals and insurance companies that seem to create most of the increase in cost and the violations. Some of the more paranoid clinicians viewed the EMR as nothing more than a tactic to gain further control of their practice and viewed Hillary Clinton as someone who would continue the onslaught on clinicians. These fines for EMR noncompliance are the first true test for the Trump administration in the area of healthcare regulation. Many of my colleagues are watching Trump and Price to see if their opposition to bureaucracy was merely lip service or has some backbone. 

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Levinson DR. Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements. Department of Health and Human Services. Office of the Inspector General. June 2017. Available at: https://oig.hhs.gov/oas/reports/region5/51400047.pdf (accessed 6/15/17).
  2. Lowes R. Proposal to take back EHR bonuses galls med societies. Medscape. June 13, 2017. Available at: http://www.medscape.com/viewarticle/881563?nlid=115819_4502&src=wnl_dne_170615_mscpedit&uac=9273DT&impID=1368453&faf=1 (accessed 6/15/17). 6
  3. Fleming NS, Aponte P, Ballard DJ, Becker E, Collinsworth A, Culler S, Kudyakov R, McCorkle R, Chang D. Exploring financial and non-financial costs and benefits of health information technology: the impact of an ambulatory electronic health record on financial and workflow in primary care practices and costs of implementation. The Agency for Healthcare Research and Quality (AHRQ). 2011. Available at: https://healthit.ahrq.gov/sites/default/files/docs/publication/R03HS018220-01Flemingfinalreport2011.pdf (accessed 6/15/17).
  4. Hayes TO. Are electronic medical records worth the costs of implementation?American Action Forum. August 6, 2015. Available at: https://www.americanactionforum.org/research/are-electronic-medical-records-worth-the-costs-of-implementation/ (accessed 6/15/17).
  5. Robbins RA. Banner hacked-3.7 million at risk. Southwest J Pulm Crit Care. 2016;13(2):80-1. [CrossRef]

Cite as: Robbins RA. EMR fines test Trump administration's opposition to bureaucracy. Southwest J Pulm Crit Care. 2017;14(6):312-4. doi: https://doi.org/10.13175/swjpcc079-17 PDF

Saturday
Jun102017

Breaking the Guidelines for Better Care 

Two events happened this past week that inspired this editorial. First, on Wednesday morning I read the editorial titled “Breaking the Rules for Better Care” by Don Berwick et al. in JAMA (1). Berwick reports a survey of about 40 hospitals done by The Institute of Healthcare Improvement (IHI). The survey asked the question “If you could break or change any rule in service of a better care experience for patients or staff, what would it be?”. The answers were not surprising. Most centered on annoying hospital rules such as visiting hours, not waking patients, correct HIPPA interpretation, and eliminating the 3-day rule. Although these are correct, in the whole they have minimal effect on healthcare. Other suggestions more likely to improve patient care included improving access, reducing wait times and earlier patient mobility. From the suggestions, it seems likely that most were from administrators. In the editorial Berwick decried, “Habits embedded in organizational behaviors, based on misinterpretations and with little to no actual foundation in legal, regulatory, or administrative requirements”. He goes on to say, “Health care leaders may be well advised to ask their clinicians, staffs, and patients which habits and rules appear to be harming care without commensurate benefits and, with prudence and circumspection, to change them.” As a clinician, I thoroughly agree with both of Berwick’s points.

Later that afternoon, I listened to a lecture by Clement Singarajah on sepsis guidelines. He reviewed the severe sepsis bundles promoted by the Surviving Sepsis Campaign and IHI, the latter being Berwick’s organization who wrote the editorial noted above (Table 1) (2,3).

Table 1.  Severe Sepsis Bundles.

The Severe Sepsis 3-Hour Resuscitation Bundle contains the following elements, to be completed within 3 hours of the time of presentation with severe sepsis:

  • Measure Lactate Level
  • Obtain Blood Cultures Prior to Administration of Antibiotics
  • Administer Broad Spectrum Antibiotics
  • Administer 30 mL/kg Crystalloid for Hypotension or Lactate ≥4 mmol/L

The 6-Hour Septic Shock Bundle contains the following elements, to be completed within 6 hours of the time of presentation with severe sepsis:

  • Apply Vasopressors (for Hypotension That Does Not Respond to Initial Fluid Resuscitation to Maintain a Mean Arterial Pressure (MAP) ≥65 mm Hg)
  • In the Event of Persistent Arterial Hypotension Despite Volume Resuscitation (Septic Shock) or Initial Lactate ≥4 mmol/L (36 mg/dL):
    • Measure Central Venous Pressure (CVP)
    • Measure Central Venous Oxygen Saturation (ScvO2)
  • Remeasure Lactate If Initial Lactate Was Elevated

We carefully reviewed each of the metrics, and concluded most were non-evidence based, outdated, or contradicted by more recent and better trials. The only exception was early antibiotic administration. Most of us reaffirmed our belief in the germ theory and felt that early administration of the correct antibiotics was probably mostly evidence-based and reasonable (4).

Is it possible that most of the metrics in the bundle are merely a waste of time as we concluded or could some be harmful? First, a recent meta-analysis examined a conservative fluid strategy in sepsis compared with a liberal strategy (the goal-directed therapy as advocated by the sepsis bundles) (5). Although there was no change in mortality, a conservative strategy resulted in increased ventilator-free days and reduced length of ICU stay. The meta-analysis concluded that the studies were underpowered to show a mortality benefit. Second, most of us had experienced delays in initiating antibiotics, the only guideline that makes a difference, while waiting for blood cultures to be drawn. None of us knew data that drawing blood cultures makes a difference in patient outcomes.

Berwick recommended asking clinicians which rules may be harming care. Rather than chiding others to do something, a good place to start might be IHI’s sepsis guidelines. The issue of continued support for non-evidence based or outdated guidelines points out the rigid dichotomy between self-delusional beliefs and science. Many (some would say most) guidelines are based on opinions and not science (6). Healthcare would be better if groups such as the Surviving Sepsis Campaign, IHI and the Centers for Medicare and Medicaid Services would follow their own advice and not burden healthcare providers with non-evidence based guidelines. Instead, they should only issue guidelines after carefully conducted, randomized, controlled trials establish a guideline rather than mandating the self-delusional beliefs of a few.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Berwick DM, Loehrer S, Gunther-Murphy C. Breaking the rules for better care. JAMA. 2017 Jun 6;317(21):2161-2. [CrossRef] [PubMed]
  2. Surviving Sepsis Campaign. Updated bundles in response to new evidence. Available at: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf (accessed 6/9/17).
  3. Institute for Healthcare Improvement. Severe sepsis bundles. Available at: http://www.ihi.org/resources/Pages/Tools/SevereSepsisBundles.aspx (accessed 6/9/17).
  4. Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017 Jun 8;376(23):2235-44. [CrossRef] [PubMed]
  5. Silversides JA, Major E, Ferguson AJ, et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017 Feb;43(2):155-170. [CrossRef] [PubMed]
  6. Lee DH, Vielemeyer O. Analysis of overall level of evidence behind Infectious Diseases Society of America practice guidelines. Arch Intern Med. 2011;171:18-22. [CrossRef] [PubMed]

Cite as: Robbins RA. Breaking the guidelines for better care. Southwest J Pulm Crit Care. 2017;14(6):285-7. doi: https://doi.org/10.13175/swjpcc072-17 PDF 

Tuesday
May162017

Worst Places to Practice Medicine 

Medscape periodically publishes a “Best” and “Worst” places to practice medicine (1). We were struck by this year’s list because three of the five worst places to practice medicine are in the Southwest (Table 1).

Table 1. Medscape’s “worst” places to practice medicine.

  1. New Orleans, Louisiana
  2. Phoenix, Arizona
  3. Las Vegas, Nevada
  4. Albuquerque, New Mexico
  5. Tulsa, Oklahoma

While Minneapolis rated the best place to practice, only 2 cities from the Southwest made the top 25 “Best” list-Salt Lake City at 13th and Colorado Springs at 24th. Most of the top 25 are from the Midwest or Northeast. None from California made the best places list and only the only Southern location was Virginia Beach, Virginia. 

Rankings resulted from the combination of twelve 50-state rankings: medical board actions per doctor; malpractice lawsuits per doctor; office-based primary care physicians per population; physician income; employer-based insurance rate per population; insurance coverage per population; reported rates of well-being of the general population; violent crime rates; participation in wildlife-related recreation; divorce rates; use of family-friendly amenities; and cost of living.

Phoenix, Las Vegas and Albuquerque were singled out for high rates of uninsured patients. Phoenix was also singled out for its moderately high malpractice suit rate.

Before everyone in the Southwest decides to move, these ratings may be meaningless, much like hospital rankings (2). Furthermore, there seems little that physicians can do to improve the situation based on the selected metrics. What can be done is to continue our efforts through our professional organizations to educate the public and their elected representatives that job satisfaction is necessary to recruit and retain physicians, as well as nurses and other health care professionals. A healthcare organization without these well-educated and caring people lacks quality and attempts to substitute substandard care is much like trying to substitute a Yugo for a Mercedes.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Page L. Best places to practice to avoid burnout. Medscape. May 10, 2017. Available at: http://www.medscape.com/viewarticle/879573 (accessed 5/16/17).
  2. Robbins RA, Gerkin RD. A comparison between hospital rankings and outcomes data. Southwest J Pulm Crit Care. 2013;7(3):196-203. [CrossRef] 

Cite as: Robbins RA. Worst places to practice medicine. Southwest J Pulm Crit Care. 2017;14(5):236-7. doi: https://doi.org/10.13175/swjpcc060-17 PDF 

Thursday
Mar162017

Pain Scales and the Opioid Crisis 

In the last year, physicians and nurses have increasingly voiced their dissatisfaction with pain as the fifth vital sign. In June 2016, the American Medical Association recommended that pain scales be removed in professional medical standards (1). In September 2016, the American Academy of Family Physicians did the same (2). A recent Medscape survey reported that over half of surveyed doctors and nurses supported removal of pain assessment as a routine vital sign (3).

In the 1990’s there was a widespread impression that pain was undertreated. Whether this was true or an impression created by a few practitioners and undertreated patients with the support of the pharmaceutical industry is unclear. Nevertheless, the prevailing thought became that identifying and quantifying pain would lead to more appropriate pain therapy. The American Society of Anesthesiologists and the American Pain Society issued practice guidelines for pain management (4,5). Subsequently, both the Department of Veterans Affairs and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated a pain scale as the fifth vital sign (6-9). Most commonly these scales ask patients to rate their pain on a scale of 1-10. The JCAHO mandated that "Pain is assessed in all patients” and would give hospitals "requirements for Improvement" if they failed to meet this standard (9). The JCAHO also published a book in 2000 for purchase as part of required continuing education seminars (9). The book cited studies that claimed "there is no evidence that addiction is a significant issue when persons are given opioids for pain control." It also called doctors' concerns about addiction side effects "inaccurate and exaggerated." The book was sponsored by Purdue Pharma makers of oxycodone.

Almost as soon as the standards were initiated, suggestions emerged that pain treatment was becoming overzealous. In 2003 a survey of 250 adults who had undergone surgical procedures reported that almost 90% were satisfied with their pain medications. Nevertheless, the authors concluded that “many patients continue to experience intense pain after surgery … additional efforts are required to improve patients’ postoperative pain experience” (8). Concerns about overaggressive treatment for pain increased after Vila et al. (10) reported in 2005 that the incidence of opioid oversedation increased from 11.0 to 24.5 per 100 000 inpatient hospital days after the hospitals implemented a numerical pain treatment algorithm. As early as 2002 the Institute for Safe Medication Practices linked overaggressive pain management to a substantial increase in oversedation and fatal respiratory depression events (11). Articles appeared questioning the wisdom of asking every patient to rate their pain noting that implementation of the scale did not appear to improve pain management (12). The JCAHO removed its standard to assess pain in all patients but not until 2009.

The US has seen a dramatic increase in the incidence of opioid deaths (13). It is unclear if adoption of the pain scale and its widespread application to all patients contributed to the increase although the time frame and the data from Vila et al. (10) suggest that this is likely.

There have been other factors that may have also contributed to the increase in opioid deaths. The Medscape survey mentioned above asked participants how often they feel pressure to prescribe pain medication in order to keep patient satisfaction levels high (3). Specifically mentioned was the Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS. HCAHPS is a patient satisfaction survey required for all hospitals in the US. About two thirds of doctors and nurses felt there was pressure (3). The survey also asked respondents about the influence of patient reviews on opioid prescribing. Forty-six percent of doctors said the reviews were more than slightly influential. The surveys seemed to carry more weight with nurses. Seventy-three percent said the reviews were influential. Others have blamed pharmaceutical company marketing opioids as a way of reducing pain and increasing patient satisfaction (14). Clearly, there has been a dramatic increase in narcotic prescriptions. Not surprisingly, pharmaceutical companies have done little to curb the use of their products.

Earlier this year, former CDC Director Tom Frieden said "The prescription overdose epidemic is doctor-driven…It can be reversed in part by doctors' actions” (15). Some physicians have taken this as blame for the entire opioid crisis, including deaths from heroin and illegal fentanyl. There may be some validity in this belief since abuse of illegal narcotics sometimes evolves out of abuse of prescribed narcotics. However, the actions of the health regulatory agencies that mandated pain scales and created guidelines for pain management were not mentioned by Dr. Frieden. Also, not mentioned are the patient satisfaction surveys. 

About a year ago the CDC issued guidelines for prescribing opioids for chronic pain (15). These guidelines were developed in collaboration with a number of federal agencies including the Department of Veterans Affairs which was one of the first to mandate pain scales and the Centers for Medicare and Medicaid Services (CMS) which mandated HCAHPS. Pain is a subjective symptom and quantification and treatment are imprecise. The goal cannot be to deliver perfect pain management but to reduce the incidence of under- and overtreatment as much as possible. Someone needs to assess patients’ pain complaints and prescribe opioids appropriately. No one is better qualified and prepared than the clinician at the bedside.

No one condones the unethical practice of widespread prescription of opioids without sufficient medical oversight. However, meddling by unqualified bureaucrats, administrators and politicians emphasizes guidelines over appropriate care. As detailed above, the present opioid crisis may be an unattended consequence of the pain scale and opioid prescribing guidelines. Further intrusion by the same groups who created the crisis is unlikely to solve the problem but is likely to create additional problems such as the undertreatment of patients with severe pain. As I write this on the ides of March it may be appropriate to paraphrase a line from Julius Cesar, “The fault lies not in our doctors but in our regulators”.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Anson P. AMA drops pain as vital sign. Pain News Network. June 16, 2016. Available at: https://www.painnewsnetwork.org/stories/2016/6/16/ama-drops-pain-as-vital-sign (accessed 3/2/17).
  2. Lowes R. Drop pain as the fifth vital sign, AAFP says. Medscape Medical News. September 22, 2016. Available at: http://www.medscape.com/viewarticle/869169 (accessed 3/2/17).
  3. Ault A. Many physicians, nurses want pain removed as fifth vital sign. Medscape Medical News. Medscape Medical News. February 21, 2017. Available at: http://www.medscape.com/viewarticle/875980?nlid=113119_3464&src=WNL_mdplsfeat_170228_mscpedit_ccmd&uac=9273DT&spon=32&impID=1299168&faf=1 (accessed 3/2/17).
  4. Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology. 1995 Apr;82(4):1071-81. [CrossRef] [PubMed]
  5. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, Lipman AG, Bookbinder M, Sanders SH, Turk DC, Carr DB. American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005 Jul 25;165(14):1574-80. [CrossRef] [PubMed]
  6. National Pain Management Coordinating Committee. Pain as the 5Th vital sign toolkit. Department of Veterans Affairs. October 2000. Available at: https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf (accessed 3/2/17).
  7. Baker DW. History of The Joint Commission's Pain Standards: Lessons for Today's Prescription Opioid Epidemic. JAMA. 2017 Mar 21;317(11):1117-8. [CrossRef] [PubMed]
  8. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540. [CrossRef] [PubMed]
  9. Moghe S. Opioid history: From 'wonder drug' to abuse epidemic. CNN. October 14, 2016. Available at: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/ (accessed 3/2/17).
  10. Vila H Jr, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg. 2005;101(2):474-480. [CrossRef] [PubMed]
  11. Institute for Safe Medication Practices. Pain scales don’t weigh every risk. July 24, 2002. Available at: https://www.ismp.org/newsletters/acutecare/articles/20020724.asp (accessed 3/2/17).
  12. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006 Jun;21(6):607-12. [CrossRef] [PubMed] 
  13. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 Dec 16;65. Published on-line. [CrossRef] [PubMed]
  14. Cha AE. The drug industry’s answer to opioid addiction: More pills. Washington Post. October 16, 2016. Available at: https://www.washingtonpost.com/national/the-drug-industrys-answer-to-opioid-addiction-more-pills/2016/10/15/181a529c-8ae4-11e6-bff0-d53f592f176e_story.html?utm_term=.36c5992fa62f (accessed 3/2/17).
  15. Lowes R. CDC issues opioid guidelines for 'doctor-driven' epidemic. Medscape. March 15, 2016. Available at: http://www.medscape.com/viewarticle/860452 (accessed 3/2/17).

Cite as: Robbins RA. Pain scales and the opioid crisis. Southwest J Pulm Crit Care. 2017;14(3):119-22. doi: https://doi.org/10.13175/swjpcc033-17 PDF 

Monday
Feb132017

In Defense of Eminence-Based Medicine 

An internal memo to the members of the Society for Truculent Underappreciated Practitioners of Inpatient Doctoring

Brigham C. Willis, MD, MEd

Department of Medical Education and Division of Cardiovascular Intensive Care
Phoenix Children's Hospital
Phoenix, AZ USA

 

To arms, august compatriots! Our very way of life is threatened by the hordes of barbarians at our gates. Armed not with pitchforks and torches, but with Cochrane reviews, “multicenter randomized controlled trials”, the Interwebs, and “tablet computers”, they besiege our traditions and values, and threaten our place in the hierarchy of medicine. In no uncertain terms, they want to remove us from our place of reverence, from our position of respect, and replace us with guidelines, pathways, and protocols. To do nothing is to perish. We must stand together, and fight this tide, or be swept away in the tidal wave of journals and statistical analyses buffeting our land. Join or Die!

For generations, we have preserved our careers and medicine itself by strictly honoring a system based on “eminence-based medicine” or “EBM”. This is the practice of making the same sound decisions with increasing confidence over an impressive number of years (some of the barbarians have even mocked and disregarded this definition, co-opting “EBM” for their own purposes and replacing “sound decisions” in the true definition with “mistakes”. The nerve.) Upon what else does our hallowed practice rest than this? Imagine the disorder and chaos if students or lowly interns were allowed to question the decisions we, the wise practitioners, make. I have seen enough patents with pyemia or blood rot in my time to know how to treat them, thank you very much. I don’t need some unwashed whelp of a trainee waiving a New England Journal article in my face, saying I am giving too much or too little fluid to the patient. I once took care of a septic patient and gave them absolutely no fluid, and they survived. So much for the so-called “evidence”. There is no amount of evidence that can replace intuition and sound clinical acumen. As many of you likely can affirm, a true clinician can almost feel the right thing to do. A challenge to this as the basis of medicine is akin to advocating a change from the “art of medicine” to the “science of medicine”. Blasphemy!

I am sure each of you have experienced some form of this assault. In fact, the medical literature today is full of direct attacks on eminence (1-3). The threat is becoming more acute by the day, as even the lowliest trainee has access to the entire world’s archive of medical literature in their pocket. To survive, we must arm ourselves and fight back. We must have at the ready an armamentarium of weapons and tools to stem the tide, and turn back the latter-day Visigoths who fling their regression analyses, critical appraisal tools, and “levels of evidence” at our battlements. What follows is an attempt to codify some of those tools, and help all of our eminent practitioners to soldier on in the fight.

  1. “Harrumph and eye roll”. When confronted with what seems like sound evidence that counters the way you have treated something for many years, simply roll your eyes in a dramatic way, make a “harrumph”-ing sound quite loudly, and say something like “Well, balanced salt solutions may make physiologic sense, but normal saline has worked for me for many years.” The italics imply rhetorically stressing the avenue of attack chosen by the challenger, and throwing it back at them in a mocking, or sarcastic way, and then reminding them of how much more experience you have than they do. While seemingly basic and perhaps puerile, it is astounding how effective this technique can be. But the “harrumph” you throw in must be emphatic, and said with conviction. This technique rests entirely on how invested in it you can be.
  2. “My specific patient is different”. These evidence cultists always want to assume that their numbers and ratios always apply to everyone. It is relatively simple to find some minor clinical difference between the particular patient under discussion and the participants in whatever trial your foe is citing. For example, when challenged on your management of a ventilated patient, you can say, “Well, in that trial, they didn’t specifically analyze the subgroup of patients with influenza and CHF, did they?” or “the secretions of influenza in a patient with CHF are clearly unique”. Defenses like this usually put them on their heels, as they will either have to go back to the trial itself to check, or admit that they are not quite sure.
  3. “In my experience…” No matter how much evidence is presented, it is always possible to unearth the musty contents of your own shadowy past. Ill-defined and utterly unverifiable, your “experiences” with individual patients, if described colorfully and in detail, can easily counter dry references to impersonal literature reports. It can also refute arguments of physiology. If you have seen something before, your eye-witness account is much more reliable than some “deep understanding of physiologic principles”.
  4. Question the quality of the training of the evidence-hound. No matter what they say or how many “facts” they can cite, one can almost always cast aspersions on their training in some way. “When I was at Harvard...” is a near-perfect oratory introduction to asserting your proper place.
  5. Point out some minute problem in the design of the study being quoted. Although somewhat unsavory, as it may require stooping to the tactics employed by our attackers, it is always possible to take issue with some aspect of any given study. “I can’t believe they used a Kolmogorov–Smirnov test, when they clearly should have used Pitman’s permutation test. The results of this study are suspect to say the least.” This should require quite a bit of investigation by the whelp, by which time you should be safely ensconced in the doctor’s lounge.
  6. Cite a report that supports your viewpoint. Again somewhat unsavory, but even when someone states that 3 randomized control trials (RCTs) have shown that a certain treatment is “clearly” superior to how you have been doing things, you can almost always cite a trial that does support you (“while it is interesting that those investigations show that digitalis is not effective in heart failure in general, Jones et al. showed that it reduced readmission rates in the Congo when given to patients with CHF due to parasitic disease...”). Always remember to end the discussion with “so clearly the jury is still out on this subject.”
  7. Lean heavily on the axiom that “lack of evidence of efficacy is not evidence of lack of efficacy”. This is very powerful and can be carried quite far. No matter how many trials show that a treatment doesn’t work, this single sentence irrefutably ends discussion in most cases.
  8. Utilize physiologic smoke screens. Delve deeply into your medical school texts, and have at the ready in depth discussions of biochemical and physiologic pathways. Learn to describe how they interact in such detail that no one can really follow what you are getting at, but throw in enough polysyllabic words and pathway intermediates and you are untouchable, no matter how much evidence is tossed around. In today’s world, most trainees’ education in biochemistry, physiology, and anatomy has been short-shrifted to a stunning degree by the addition of silly classes on biostatistics, ethics, diversity, professionalism, and other such drivel, so you can be generally assured they will have no comeback for this defense.
  9. “Cookbook medicine”. Throw out derogatory terms such as “cookbook medicine” and wax nostalgic for the times when doctors truly “thought” about their patients and cared about them. This is particularly effective when you can question the humanity of your foe, asserting that “statistics and numbers can never substitute for the human being in the bed in front of you. You would do well to remember that.” Followed up with a moving patient story where your attention to detail and the history of that individual patient made all the difference, and where your diagnosis and treatment plan flew in the face of the naysayers, and you are safe.
  10. Parachutes. Go nuclear, and question evidence itself. This is obviously high-risk, but can be very effective. Building on the excellent article utilizing the example of the parachute as a preventative treatment for high-altitude falls that has never been verified in a RCT (despite the fact that there are case reports of parachute-less high-altitude falls resulting in subject survival) (4), make the point that medicine is more than evidence. Rub their nose in the fact that true doctors can see the value in treatments that are of “obvious” value, even without evidence.
  11. Question the work ethic or integrity of the evidence bearer. No matter what they say, find some fault with their daily routine, or pre-rounding attention to detail, or accuracy of information they provided about the patient. Proceed to vociferously point out their deficiencies, making sure that everyone in ear shot is aware of what is happening, and intimate that anything they say is suspect.
  12. Trump them. If all else fails, utilize the debate technique made so famous by the current president. Previously known as “vehemence-based medicine” (5), simply raising the volume of your opinion and employing an attitude that your opponent is a complete and utter moron will shut down any opposition. With this technique, if employed correctly, any amount of logic or number of facts will wilt in the glare of your intensity and scorn.
  13. Eloquence and elegance based argumentation. Much to the chagrin of the attackers, it is still well-accepted that “brilliant oratory,…a year round suntan, [and/or] a silk suit” (5) can overwhelm the senses of most of the sandal-wearing hippies who worship at the altar of evidence. Keep your style impressive and tighten your bowties!

Be strong, my brothers and sisters! While some furtive attempts have been made to fight back and harness the power of our eminence (6), we are clearly in danger. In the face of this growing threat, our ability to wield our eminence may falter. We hope that the techniques described herein will serve you well in our struggle. Let not these heathens question our place or sacred way of life. Stand tall, and continue to be the face of “EBM”.

References

  1. Bhandari M, Zlowodzki M, Cole PA. From eminence-based practice to evidence-based practice: a paradigm shift. Minn Med. 2004 Apr;87(4):51-4. [PubMed]
  2. Kros JM. Grading of gliomas: the road from eminence to evidence. J Neuropathol Exp Neurol. 2011 Feb;70(2):101-9. [CrossRef] [PubMed]
  3. Pincus T, Tugwell P. Shouldn't standard rheumatology clinical care be evidence-based rather than eminence-based, eloquence-based, or elegance-based? J Rheumatol. 2007 Jan;34(1):1-4. [PubMed]
  4. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003 Dec 20;327(7429):1459-61. [CrossRef] [PubMed]
  5. Isaacs D, Fitzgerald D. Seven alternatives to evidence based medicine. BMJ. 1999 Dec 18-25;319(7225):1618. [CrossRef] [PubMed]
  6. Hay MC, Weisner TS, Subramanian S, Duan N, Niedzinski EJ, Kravitz RL.Harnessing experience: exploring the gap between evidence-based medicine and clinical practice. J Eval Clin Pract. 2008 Oct;14(5):707-13. [CrossRef] [PubMed]

Cite as: Willis BC. In defense of eminence-based medicine. Southwest J Pulm Crit Care. 2017;14(2):69-72. doi: https://doi.org/10.13175/swjpcc019-17 PDF 

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