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Why a Doctor Would Be Relieved When a New Study Fails To Reduce Deaths

I don’t want a world where all actions are predetermined by written protocol and in which we are obliged to act like bureaucrats without ever exercising our individual judgment.

by
Theodore Dalrymple

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May 13, 2014 - 7:30 am
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edison-on-failure

Sometimes the New England Journal of Medicine reads like a journal of failed bright ideas. I do not remember ever having read of so many failed trials of treatment as I have recently, but perhaps that is a sign of increasing scientific honesty. After all, it is as important to know what does not work as what does, especially when what does not work is very expensive to administer.

Septic shock is a condition of dangerously low blood pressure brought about by serious infection. About 750,000 cases a year are treated in the United States alone, with a death rate above 20 percent, that is to say at least 150,000 people die of it each year. This is a number well worth reducing.

More than a decade ago the results of a trial were published in which it was shown that aggressive treatment according to a pre-arrange protocol could reduce the death rate from septic shock by about a half. In those days (medicine 10 years ago seems that of a bygone era), the death rate in septic shock was much higher than it is today, which may in part explain the success of that trial compared with the failure of a more recent trial published recently in the NEJM. 

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Top Rated Comments   
Have to agree with MT Geoff. I thought you were going to write about a protocol that failed to show improvement, and at least feel relieved that you haven't been killing people (or not saving somewhat more of them) for the last twenty years. And even some protocols that do show improvement may also have indications and limitations that call for educated, wise judgement.

But to complain about being a checklist operator - surely you mean, you don't want to be overridden by some admin with nothing but six continuing education credits in medicine, second-guessing every treatment? But you get that anyway, you get that in all cases.

Back in the 1980s when they were fooling around with "expert systems", it peeved doctors no end that some dumb, little program could sort through reported symptoms better than most doctors tested. That's nothing to brag about! Doctors are just people too, and like all of us these days I'm sure are getting cyborged by their smart phones and wifi and Google and the Internet and patients who sit in their hospital beds looking up alternate treatments!

As irritating as that has to be to the classic doctor-knows-best model, I count it as major progress. I've seen too much of the DKB model and I know it was never the case - half the doctors practicing are below average, and for that there is no cure. And don't even get me started on doctors who never really keep up on anything after they leave medical school - which in many cases teaches only what was standard twenty years earlier!

Have to get that average up, and keep it current - as your article describes. And frankly, even the best can use the help. You can't even be the best anymore without all the technology.
22 weeks ago
22 weeks ago Link To Comment
I'm going to throw a flag on this one, Dr. Dalyrimple.
I've been a paramedic in my day and I've been a nurse, so I have a medical background. When there's a truly effective treatment protocol, one that can be worked like a checklist or flowchart, that's a very good thing. It does not remove judgment from the case, or should not; it should guide and inform the judgment.
Very many medical problems lend themselves to treatment protocols, to the benefit of patient and provider both. I understand wanting to be a physician, not a checklist operator, but effective protocols and medical judgment work together.
22 weeks ago
22 weeks ago Link To Comment
All Comments   (3)
All Comments   (3)
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Have to agree with MT Geoff. I thought you were going to write about a protocol that failed to show improvement, and at least feel relieved that you haven't been killing people (or not saving somewhat more of them) for the last twenty years. And even some protocols that do show improvement may also have indications and limitations that call for educated, wise judgement.

But to complain about being a checklist operator - surely you mean, you don't want to be overridden by some admin with nothing but six continuing education credits in medicine, second-guessing every treatment? But you get that anyway, you get that in all cases.

Back in the 1980s when they were fooling around with "expert systems", it peeved doctors no end that some dumb, little program could sort through reported symptoms better than most doctors tested. That's nothing to brag about! Doctors are just people too, and like all of us these days I'm sure are getting cyborged by their smart phones and wifi and Google and the Internet and patients who sit in their hospital beds looking up alternate treatments!

As irritating as that has to be to the classic doctor-knows-best model, I count it as major progress. I've seen too much of the DKB model and I know it was never the case - half the doctors practicing are below average, and for that there is no cure. And don't even get me started on doctors who never really keep up on anything after they leave medical school - which in many cases teaches only what was standard twenty years earlier!

Have to get that average up, and keep it current - as your article describes. And frankly, even the best can use the help. You can't even be the best anymore without all the technology.
22 weeks ago
22 weeks ago Link To Comment
I'm going to throw a flag on this one, Dr. Dalyrimple.
I've been a paramedic in my day and I've been a nurse, so I have a medical background. When there's a truly effective treatment protocol, one that can be worked like a checklist or flowchart, that's a very good thing. It does not remove judgment from the case, or should not; it should guide and inform the judgment.
Very many medical problems lend themselves to treatment protocols, to the benefit of patient and provider both. I understand wanting to be a physician, not a checklist operator, but effective protocols and medical judgment work together.
22 weeks ago
22 weeks ago Link To Comment
"effective protocols and medical judgment work together."

Yes.

And how are effective protocols established? Observation, judgement, hypothesizing, experimenting, re-hypothesizing, experimenting some more.

In other words, science.

Protocols aren't a problem, they are a help.

Mindless automatons who want to operate by blindly applying protocols are a problem, but the cure isn't getting rid of protocols, it's getting rid of mindless automatons.

Especially those with PhD or MD after their names.

It's a perpetual battle.


22 weeks ago
22 weeks ago Link To Comment
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