Letters from Maine

Decisions, Decisions


Let me begin by saying that I agree with those who feel our decision-making habits could use some spiffing up. We should not be choosing medications based on what our local pharmaceutical representatives tell us over a sumptuous meal at a nice little French restaurant. Nor should we be ordering lab tests out of fear that we will be sued for missing a rare and extremely unlikely disease. Nor should we continue to recommend a certain therapy because that's the way we've been doing it since we finished our residencies.

I agree that medical decisions (and probably all of our decisions) should reflect the best evidence available. However, I am having trouble wrapping my mind and my heart around many of the strategies that I encounter in articles about how I might practice evidence-based medicine. For the most part, they seem unrealistic and impractical.

Let's start with the initial premise that there is enough good evidence out there to support my decisions. New studies are being performed at such a rate that what seems to be correct information today may well be hogwash tomorrow. Yes, there are statistical manipulations that can help sort out the wheat from the chaff, none with a clear advantage. But I don't think that someone can reasonably expect most primary care pediatricians to carry these kinds of analytical skills in our decision-making “tool boxes.”

It's not that we are stupid. It's just that we don't have the time to stop the merry-go-round long enough to do the footwork to perform these analyses. A computer can help, but I'm sure you have discovered that once you open up the Internet, time flies. An extra click here or there and before you know it a half an hour has zipped by.

So how can we make more rational decisions? First, many of the good evidence-based studies I have read (and trust) often suggest that what we've been doing out of habit and tradition isn't achieving our goals. The authors usually suggest further studies, but for the moment doing nothing sounds like the better course of action for those of us in the trenches. Therefore, I recommend we begin teaching medical students how to do nothing.

This isn't as crazy as it sounds. The therapeutic nihilists who trained me are long gone, so this will mean a new core curriculum that teaches young doctors how to just stand there instead of doing something for which there is no good evidence. One must learn the best body language to adopt while standing inert, and some comforting and reassuring words to say that can help parents understand and accept our inaction. Nihilism also can save money and lives by minimizing expensive tests and risky interventions.

A second and related strategy involves learning how to stop the clock. A recent article posed a scenario in which a primary care physician is consulted by an ENT specialist about the safety of doing elective surgery on a child with both a personal and family history that suggests a bleeding disorder (Pediatr. Rev. 2009;30:317–22).

The recommended approach included searching for several articles and then applying a formula to determine probability and likelihood ratios. The issue of time was never raised in the article, but in my experience, the real scenario would have to include the fact that the call from the ENT came at 4:30 in the afternoon and surgery was scheduled for 7:30 the next morning. Why? Because that's the way it always is.

Good decisions can take time and searching for evidence can take even more time. A shortage of time can contribute to bad decisions. Sometimes we need to be bolder about asking for more time to make our decisions. If I were faced with this scenario I would have picked up the phone and asked Ann, my saintly hematologist friend down in Portland, what she would do.

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