Letters from Maine

Turns in the Road


A physician trying to follow the best practice path had better be prepared for a bumpy and tortuous ride. Years ago we were handed maps in the form of textbooks. New editions were updated every decade or so. But, the practitioner could reasonably rely on even a slightly outdated edition for guidance. As the pace of change in medicine increased, traditional hard copy texts lost much of their reliability.

More immediate electronic forms of information sharing have begun to replace hard copy books and supplement paper journals. The volume of information and the pace of change at times are so great that the busy physician may feel he doesn’t have the time to pull off on the shoulder to consult them. Instead, he speeds along looking for helpful road signs for direction. Unfortunately, the landscape is dominated by billboards erected by drug companies. Even the most conscientious physician can be distracted at times by these advertisements as he searches for the route to best practice.

Recently, I’ve been trying to remember how I arrived at my current strategy for managing asthma. It began when I learned in medical school that asthma was a disease characterized by "attacks." As a house officer, I was taught how to "break" these attacks with epinephrine injections (some older physicians were still using ipecac). We began using theophylline preparations and aminophylline drips. In my early days of practice I was prescribing oral albuterol and occasionally systemic steroids. At some point – but I don’t remember when or how – I began prescribing inhaled albuterol. Nebulizers, once reserved for the most seriously ill, became so common that if a family needed one in a pinch they could easily find a neighbor who had one in the closet. I now consider asthma a chronic disease and manage it with inhaled steroids and "rescue" inhalers.

How did I find my way? I can’t remember any sharp turns in the road. I guess it was a gradual process of talking with peers and former instructors, taking a rare CME course, and snatching a few moments to scan a journal here and there.

It feels as though most of the changes I’ve made in how I practice have been a collection of gentle turns. However, every now and then the route has taken a sharp 180-degree U-turn. The most dramatic example I can think of is the "Back to Sleep" initiative. It happened so many years ago that I suspect more than half the pediatricians practicing today have never told a mother to put her baby in the crib to sleep face down. This was not easy for those of us who had to change our tune in the blink of an eye.

The management of corneal abrasions is another clinical flip flop that has come recently. Now I’m left with a large box of eye patch pads that may never be used. I’m happy to have pivoted away from torturing toddlers who have fractured clavicles with figure-of-eight strapping. It always seemed like a bad idea.

However, I am a bit ambivalent about not casting simple buckle fractures. I accept the fact that a splint is not only just as good, but better. But I took great pride in crafting my own fiberglass sculptures, and then seeing them several weeks later cleverly decorated by the patient and his friends.

I guess the message is to not fall in love with one way of doing things, because more than likely time is going to make it obsolete. And, although most changes in the way we practice will be gradual, every now and then there comes a sharp 180 degree turn, and we need to keep our eyes on the road.

This column, Letters From Maine, appears regularly in Pediatric News, a publication of Frontline Medical Communicaitons. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@elsevier.com.

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