Recently I had the occasion to tell my 10-year old an old secret: until I was into my forties, I had a strong belief that the rest of the people in the world knew something I did not know. I don't mean just about stuff I do not know, but about everything! It was unnerving, anxiety-provoking and self-defeating. Until one day I had the epiphany that most humans feel this way, not just me. So, be humbled by not knowing and move on.
Yet even more recently this line of self-examination has led me to the conclusion that I end up saying "I don't know" a lot. I read a definitive tweet from someone I respect, and I say to myself "I don't know"; I read a new paper in a journal and say, "Gee, I don't know", I hear a political speech, and I walk away saying, "I just don't know." Is it that I am an idiot, or intellectually lazy? Perhaps. But what is occurring to me more and more lately is that what we are convinced of today will be much less certain and obvious tomorrow, barring some truly sacred cows. This is called growth, and as far as I can tell is a desirable development.
On the other hand, saying "I don't know" sometimes means that it just does not make sense to take sides. I know that we have to apply current knowledge and not wait for perfect information, but I still do not see getting all polar about stuff. Most of the time we act like there are only two possibilities, and they are diametrically opposed to one another. Well these are false dichotomies promoted by our educational system, which drills into us the idea that there are only two answers to any question: the right one and the wrong one. What if this is untrue? What if we change the way we think about the world, and instead of seeing only the black and the white, the left and the right, the correct and the incorrect, we start really seeing the entire continuum of possibilities? What a fantastic variety of solutions we might stumble upon to our perennial questions!
A nice mind game could be trying to think about stuff without using words. Can we do that? It is thoroughly difficult, yet it is language that seems to bracket our conceptual understanding of the world within and around us. Take the word "race" or "gender", for example. These are human-made and defined terms, which are meant to distinguish rather than merge. Yet just think how uncomfortable we can be made by a person with an ambiguous gender identity, say. Why? Because he/she does not fit into our preconceived dichotomy? Uncertainty is uncomfortable, and dichotomies cure uncertainty. But I am not sure that nature is all that into dichotomies.
The human brain is wired for "belonging." I believe it is for this reason we gravitate to our respective extreme corners of thinking and being, instead of meeting somewhere in the isle. The isle is an uncomfortable place, yet that is where we must aim to be. All the borders we have created are imaginary separations. Instead we can reposition them as the glue that unifies that which lies to either side.
Here is to not knowing more!
Showing posts with label Buddhism. Show all posts
Showing posts with label Buddhism. Show all posts
Friday, May 20, 2011
Monday, November 1, 2010
Cutting for evidence
Abe Verghese is not a fan of evidence. Well, to be precise, he is not a fan of evidence-based medicine. To be even more precise, he is not a fan of applying evidence-based medicine to the exclusion of all other ways of caring for patients. How do I know this? He said it. In those words.
I am at the annual meeting of the American College of Chest Physicians in Vancouver, where Dr. Abraham Verghese gave a keynote address this afternoon. These meeting are flat-out events for me, with a lot of work, very little sleep, and a different time zone added to the mix. So, some of what I say may be driven by raw emotion, as the more rational bits may be napping while I write this. Yet, when did this vital piece of human fabric become an insult? We are made of emotion, and there is no reason not to let it enter a discussion, to balance rationality. So, no apologies.
First, a disclaimer: I am a huge fan of Abe's -- I read his Cutting for Stone this past summer and thought it was one of the most brilliantly conceived and told stories ever, and this includes Tolstoy and Dostoyevsky. It enriched me and, equally importantly, it made me proud to be a member, no matter how peripheral, of what is really a noble and caring profession. I was so incredibly excited that Dr. Verghese would keynote our meeting -- I thought it showed real vision on the part of our President Dr. Kalpalatha Guntupalli (thankfully, everyone calls her Kay) to have this multi-talented man talk at what is usually a very dry data-driven venue. And I was not disappointed.
Dr. Verghese's talk was titled "Percussing the Chest in the Era of Homo Technologicus". It was a far ranging and erudite discussion of where we have been as a profession, where we are today, and what we have lost by giving up our physical presence at the bedside. Well, I don't mean presence altogether, but the unhurried mindful attention that doctors used to be known for has, as a rule evaporated. And this is a bad thing. Abe focused on the importance of the bedside physical exam, as that is one of the skills he so clearly excels at -- just reading his book makes clear what a brilliant diagnostician he is! In his understated, unrushed and witty way he captivated the audience with the wonders and intricacies of deciphering signs and symptoms of disease. Looking around I detected, in this brief respite from the manic pace of their every-day existence to keep just ahead of the bureaucratic avalanche of modern-day healthcare, physicians in the audience, starry eyed, "looking younger than their stated age", were clearly remembering those more idealistic days of med school and training, when all that mattered was the patient and the calling. This was a time before quality measures and protocols and check lists and MD grades and all the stuff that makes their heads spin outside this cocoon of annual professional exchange.
So, by wanting to go back to the low-tech encounter between two people, the patient and the doctor, was Dr. Verghese advocating willful ignorance? Was he saying that we should walk away from science and back into the age of medicine without antibiotics, a time before we could literally see through life with our imaging technologies, before our patients became a grouping of tissues and cells and molecules and paperwork? Well, no, not really. His argument was nuanced. Analytic evidence is important. So is the art of medicine. Using one without the other unbalances the equation and diminishes the effectiveness (and importance) of the therapeutic relationship itself.
There was one striking feature of Abe's presentation: unless I missed it, the only numbers he presented were the years corresponding to the historic artifacts and concepts that he discussed. There were no percentage symbols, no p values; no t-tests were hurt in the production of his talk. He used his hands to circumscribe his arguments. The hands that have brought comfort to many a patient at the end of the line, those relegated to unmanageable, untreatable, crazy. He used no data, just anecdotes. And patient e-mails in response to the New York Times article about him. Was this some kind of a cult indoctrination designed to deceive the gullible? Where was the evidence in all of this?
Well, the proof, as they say, is in the pudding. And while I vaguely remember from high school physics that this refers to some experiment by Rutherford, I am pretty sure that I can trust social sciences on this, as well as my own experience (perish the thought) of human nature: we need to hold hands. That is our instinct and our biological destiny. Do we need statistical evidence for this? Perhaps you do, but I do not. Is that heresy? Perhaps it is. Yet I trust my instincts on this enough to know that most of us wish that a doctor could focus on us, rather than our insurance or the next patient on the schedule, and apply the best evidence available to help us out in our hour of need. But for this to happen we need to stop worshipping at the altar of technology, and even the altar of evidence. Evidence is an easy target for subversion by bureaucrats looking for certainty. But to a competent and caring doctor evidence is just a tool in the belt filled with equal parts knowledge and compassion.
It is the bedside interaction and individual judgment in the context of evidence that were originally advocated by Cochrane, Sackett and Eddy. Do we need to do a randomized controlled trial of a physician's attention and the art of the physical exam to have the necessary data to push the pendulum back to where it ought to be? I, for one, do not think so, as in this respect I trust other ways of knowing. Mine and others' brains cannot be so addled as to be mistaken about this obvious truth, can they?
Regardless of where your threshold for evidence lies, we cannot ignore the dismantling of the doctor-patent relationship, the overuse of technology in the place of listening, feeling and percussing. Does the relationship provide a placebo effect? Perhaps. But, as you already know, I am not opposed to harvesting its positive fruit. And if the doctor gets less harried and the patient gets happier in the process, what's bad about that?
Once again, the Buddha's middle way may be just the antidote to the current excesses of our academic extremism. I was taught to treat the patient, not the numbers or the images. Again, thanks, Dr. Verghese, for putting the spotlight back where it belongs and giving context to the evidence. This is one boat drifting off course soon to be lost at sea. Does anyone remember where we left the anchor?
I am at the annual meeting of the American College of Chest Physicians in Vancouver, where Dr. Abraham Verghese gave a keynote address this afternoon. These meeting are flat-out events for me, with a lot of work, very little sleep, and a different time zone added to the mix. So, some of what I say may be driven by raw emotion, as the more rational bits may be napping while I write this. Yet, when did this vital piece of human fabric become an insult? We are made of emotion, and there is no reason not to let it enter a discussion, to balance rationality. So, no apologies.
First, a disclaimer: I am a huge fan of Abe's -- I read his Cutting for Stone this past summer and thought it was one of the most brilliantly conceived and told stories ever, and this includes Tolstoy and Dostoyevsky. It enriched me and, equally importantly, it made me proud to be a member, no matter how peripheral, of what is really a noble and caring profession. I was so incredibly excited that Dr. Verghese would keynote our meeting -- I thought it showed real vision on the part of our President Dr. Kalpalatha Guntupalli (thankfully, everyone calls her Kay) to have this multi-talented man talk at what is usually a very dry data-driven venue. And I was not disappointed.
Dr. Verghese's talk was titled "Percussing the Chest in the Era of Homo Technologicus". It was a far ranging and erudite discussion of where we have been as a profession, where we are today, and what we have lost by giving up our physical presence at the bedside. Well, I don't mean presence altogether, but the unhurried mindful attention that doctors used to be known for has, as a rule evaporated. And this is a bad thing. Abe focused on the importance of the bedside physical exam, as that is one of the skills he so clearly excels at -- just reading his book makes clear what a brilliant diagnostician he is! In his understated, unrushed and witty way he captivated the audience with the wonders and intricacies of deciphering signs and symptoms of disease. Looking around I detected, in this brief respite from the manic pace of their every-day existence to keep just ahead of the bureaucratic avalanche of modern-day healthcare, physicians in the audience, starry eyed, "looking younger than their stated age", were clearly remembering those more idealistic days of med school and training, when all that mattered was the patient and the calling. This was a time before quality measures and protocols and check lists and MD grades and all the stuff that makes their heads spin outside this cocoon of annual professional exchange.
So, by wanting to go back to the low-tech encounter between two people, the patient and the doctor, was Dr. Verghese advocating willful ignorance? Was he saying that we should walk away from science and back into the age of medicine without antibiotics, a time before we could literally see through life with our imaging technologies, before our patients became a grouping of tissues and cells and molecules and paperwork? Well, no, not really. His argument was nuanced. Analytic evidence is important. So is the art of medicine. Using one without the other unbalances the equation and diminishes the effectiveness (and importance) of the therapeutic relationship itself.
There was one striking feature of Abe's presentation: unless I missed it, the only numbers he presented were the years corresponding to the historic artifacts and concepts that he discussed. There were no percentage symbols, no p values; no t-tests were hurt in the production of his talk. He used his hands to circumscribe his arguments. The hands that have brought comfort to many a patient at the end of the line, those relegated to unmanageable, untreatable, crazy. He used no data, just anecdotes. And patient e-mails in response to the New York Times article about him. Was this some kind of a cult indoctrination designed to deceive the gullible? Where was the evidence in all of this?
Well, the proof, as they say, is in the pudding. And while I vaguely remember from high school physics that this refers to some experiment by Rutherford, I am pretty sure that I can trust social sciences on this, as well as my own experience (perish the thought) of human nature: we need to hold hands. That is our instinct and our biological destiny. Do we need statistical evidence for this? Perhaps you do, but I do not. Is that heresy? Perhaps it is. Yet I trust my instincts on this enough to know that most of us wish that a doctor could focus on us, rather than our insurance or the next patient on the schedule, and apply the best evidence available to help us out in our hour of need. But for this to happen we need to stop worshipping at the altar of technology, and even the altar of evidence. Evidence is an easy target for subversion by bureaucrats looking for certainty. But to a competent and caring doctor evidence is just a tool in the belt filled with equal parts knowledge and compassion.
It is the bedside interaction and individual judgment in the context of evidence that were originally advocated by Cochrane, Sackett and Eddy. Do we need to do a randomized controlled trial of a physician's attention and the art of the physical exam to have the necessary data to push the pendulum back to where it ought to be? I, for one, do not think so, as in this respect I trust other ways of knowing. Mine and others' brains cannot be so addled as to be mistaken about this obvious truth, can they?
Regardless of where your threshold for evidence lies, we cannot ignore the dismantling of the doctor-patent relationship, the overuse of technology in the place of listening, feeling and percussing. Does the relationship provide a placebo effect? Perhaps. But, as you already know, I am not opposed to harvesting its positive fruit. And if the doctor gets less harried and the patient gets happier in the process, what's bad about that?
Once again, the Buddha's middle way may be just the antidote to the current excesses of our academic extremism. I was taught to treat the patient, not the numbers or the images. Again, thanks, Dr. Verghese, for putting the spotlight back where it belongs and giving context to the evidence. This is one boat drifting off course soon to be lost at sea. Does anyone remember where we left the anchor?
Monday, April 19, 2010
What's in a name or the furor over the proposed PA name change
Much like many other news items, I came upon the one about the proposed name change for Physician Assistants quite by accident: it came to me as an e-mail notification of a new topic being discussed on one of the physician only discussion boards that I am a part of. Apparently, after 40+ years of the profession's existence, there is a grassroots effort afoot to upgrade the name, and presumably the clout, to Physician Associate.
Well, as you can imagine, while the move is met with praise by the PA profession, the MD profession is seething. Some of the comments that I have seen from my colleagues betray such tremendous pain and suffering as a profession that it threatens my equanimity: I feel organically how lost we are as a profession to be expressing such bile without much thought over what appears to be a relatively innocuous event. But surprised I am not, and here is why. The medical profession's victory over all other potential modalities is hard-won and filled with a history of major turf battles and occasional demagoguery. The historically either-or approach of modern-day practice of medicine is responsible for the current landscape of our healthcare. In short, physicians have been only too successful at becoming the final word in health, at the exclusion of all others. With the allied providers, such as nurse practitioners and PAs, gaining in importance, particularly at this time of great uncertainty about the future of our healthcare "system", understandably the MDs are reflexively bracing themselves for any and all turf battles. So, the perception of a power grab that this proposed name change has engendered in my hallowed profession is a classic fight-or-flight response, an activation of the survival instinct.
There are several aspects of this response that I find disturbing. At the most basic level, the response betrays such tremendous emotional pain among so many good people that it is all I can do to keep myself from sinking into a depression. And while I feel compassion for them, I am also forced to remind them that, as Eleanor Roosevelt once said, "No one can make you feel inferior without your consent". Applying the thought to the current situation, how the society may view PAs, whether they are called assistants or associates, should have absolutely no bearing on how physicians are perceived. Simply put, this perceived elevation in the status of the PAs relative to that of the MDs should not in any way make the MD profession diminish in its or the public's view.
The next layer of why this is a dysfunctional response lies in a poor choice of battles that this represents. I once had a boss, whom, despite working for myself currently, I frequently allude to as "the best boss I have ever had". When I would get hot under the collar, she would pointedly ask me to clarify for myself whether this was an issue to fall on my dagger for, thus teaching me that falling on my dagger too many times would make me politically into Swiss cheese, or, worse yet, dead. Under the circumstances, do MDs and their organizations really feel that this is an important dagger to fall on? In the current atmosphere of public distrust rightly or wrongly bestowed upon the profession, such indiscriminate issue picking will rightfully appear self-serving.
Finally, for a profession with, on average, a very high intelligence quotient, I am amazed that we are focusing on the minutia instead of looking at the big picture. Healthcare is a behemoth, an inefficient and inequitable trough at which there has been a feeding frenzy for too long. We need to be reining it in to the best of our abilities. And yes, altruism, not unmitigated self-interest should be driving us to do this. Gentleness toward and respect for each other, our communities and our planet should be the values that determine our actions as a profession. I am convinced that these are the values that brought us into medicine.
These are difficult times, made more so by the external forces all ganging up to deprive us of our humanity. Let's get back to the reasons why we went into medicine; let's sit quietly and find that lost thread of contentment and pride. Or else, if there is no joy left for you in your practice, resolve to find something else that you can be happy about. And no, it is not easier said than done. It is much more difficult to go through life carrying the baggage of self-imposed misery than to set it down in favor of finding happiness in this brief sojourn that is our life.
Well, as you can imagine, while the move is met with praise by the PA profession, the MD profession is seething. Some of the comments that I have seen from my colleagues betray such tremendous pain and suffering as a profession that it threatens my equanimity: I feel organically how lost we are as a profession to be expressing such bile without much thought over what appears to be a relatively innocuous event. But surprised I am not, and here is why. The medical profession's victory over all other potential modalities is hard-won and filled with a history of major turf battles and occasional demagoguery. The historically either-or approach of modern-day practice of medicine is responsible for the current landscape of our healthcare. In short, physicians have been only too successful at becoming the final word in health, at the exclusion of all others. With the allied providers, such as nurse practitioners and PAs, gaining in importance, particularly at this time of great uncertainty about the future of our healthcare "system", understandably the MDs are reflexively bracing themselves for any and all turf battles. So, the perception of a power grab that this proposed name change has engendered in my hallowed profession is a classic fight-or-flight response, an activation of the survival instinct.
There are several aspects of this response that I find disturbing. At the most basic level, the response betrays such tremendous emotional pain among so many good people that it is all I can do to keep myself from sinking into a depression. And while I feel compassion for them, I am also forced to remind them that, as Eleanor Roosevelt once said, "No one can make you feel inferior without your consent". Applying the thought to the current situation, how the society may view PAs, whether they are called assistants or associates, should have absolutely no bearing on how physicians are perceived. Simply put, this perceived elevation in the status of the PAs relative to that of the MDs should not in any way make the MD profession diminish in its or the public's view.
The next layer of why this is a dysfunctional response lies in a poor choice of battles that this represents. I once had a boss, whom, despite working for myself currently, I frequently allude to as "the best boss I have ever had". When I would get hot under the collar, she would pointedly ask me to clarify for myself whether this was an issue to fall on my dagger for, thus teaching me that falling on my dagger too many times would make me politically into Swiss cheese, or, worse yet, dead. Under the circumstances, do MDs and their organizations really feel that this is an important dagger to fall on? In the current atmosphere of public distrust rightly or wrongly bestowed upon the profession, such indiscriminate issue picking will rightfully appear self-serving.
Finally, for a profession with, on average, a very high intelligence quotient, I am amazed that we are focusing on the minutia instead of looking at the big picture. Healthcare is a behemoth, an inefficient and inequitable trough at which there has been a feeding frenzy for too long. We need to be reining it in to the best of our abilities. And yes, altruism, not unmitigated self-interest should be driving us to do this. Gentleness toward and respect for each other, our communities and our planet should be the values that determine our actions as a profession. I am convinced that these are the values that brought us into medicine.
These are difficult times, made more so by the external forces all ganging up to deprive us of our humanity. Let's get back to the reasons why we went into medicine; let's sit quietly and find that lost thread of contentment and pride. Or else, if there is no joy left for you in your practice, resolve to find something else that you can be happy about. And no, it is not easier said than done. It is much more difficult to go through life carrying the baggage of self-imposed misery than to set it down in favor of finding happiness in this brief sojourn that is our life.
Tuesday, April 6, 2010
Evidence: What the bleep do we really know?
So I know that my blogging has fallen off a bit, and I am sure you are all sorely disappointed (or not). Let me try to explain why.
There are several things going on to nudge me toward the next rung in the evolution of my thinking about healthcare and evidence. The event most responsible for this re-examination of my assumptions is the previously-mentioned illness of a loved one, along with my need to be closely involved with his care decisions. I think that I have generally adequately voiced my frustration with how decisions are made in our healthcare system, and where the switches for these choices should be as opposed to where they are. I am even more convinced now that by the time the physician and the family are considering expensive options with marginal effectiveness, the cat is already out of the bag: how can either the distraught family or the committed healthcare provider not consider those, despite shaky evidence of the value?
But this is not all. I have actually been cogitating the entire way we do evidence and evidence-based medicine. When we invoke evidence, we generally talk about some scientific study's findings, or a group of studies either showing similar or differing results. Let's keep stepping back and looking at the components. The scientific community, based on some statistical and other methodological considerations has come to a consensus around what constitutes valid study designs. This consensus is based on a profound understanding of the tools available to us to answer the questions at hand. The key concept here is that of "available tools". As new tools become available, we introduce them into our research armamentarium to go deeper and further. What we need to appreciate, however, is that "deeper" and "further" are directional words: they imply the same direction as before, only beyond the current stopping point. This is a natural way for us to think, since even our tools are built on the foundation of what has been used previously.
So, what emerges is a picture of being emotionally committed to a certain way of viewing the question, the processes of answering it and the actual answers. And what if by narrowing ourselves to this one particular way of examining the world, to this one particular way to collect and interpret the evidence, we have effectively ignored all other possibilities?
Let me try to clarify what I mean a little further. We spend our days walking through waves. Some of these waves we can detect through our own senses: sound, light, for example. Others we need special external "receptors" to detect, such as radio and micro-waves. Is it possible that there are some other, heretofore unknown waves (or other phenomena) that are around us that we are unable to attune to because of our biology? Is it kooky to think that this is possible, or is it simply blind to walk away from such possibility?
The answer may be that it is both. Nevertheless, it is highly likely that there are many biological phenomena that are not amenable to being examined through our narrow prism of current methodology. We as scientists and clinicians need to be open to this possibility. The Buddha said that both preachers and scholars are blind because they constantly commit themselves to partially-seen truths. Given the shambles in which we find not only our nation's healthcare system, but also the health of its citizens, this would be a great time for this epiphany to penetrate our collective psyche and strive toward a broader view of possibilities. Let's give up the arrogance of ignorance in favor of the humbleness of enlightenment.
And these are my latest thoughts. I am not saying that they are the only way or that they are even remotely correct. But here they are nevertheless. Do with them what you will.
There are several things going on to nudge me toward the next rung in the evolution of my thinking about healthcare and evidence. The event most responsible for this re-examination of my assumptions is the previously-mentioned illness of a loved one, along with my need to be closely involved with his care decisions. I think that I have generally adequately voiced my frustration with how decisions are made in our healthcare system, and where the switches for these choices should be as opposed to where they are. I am even more convinced now that by the time the physician and the family are considering expensive options with marginal effectiveness, the cat is already out of the bag: how can either the distraught family or the committed healthcare provider not consider those, despite shaky evidence of the value?
But this is not all. I have actually been cogitating the entire way we do evidence and evidence-based medicine. When we invoke evidence, we generally talk about some scientific study's findings, or a group of studies either showing similar or differing results. Let's keep stepping back and looking at the components. The scientific community, based on some statistical and other methodological considerations has come to a consensus around what constitutes valid study designs. This consensus is based on a profound understanding of the tools available to us to answer the questions at hand. The key concept here is that of "available tools". As new tools become available, we introduce them into our research armamentarium to go deeper and further. What we need to appreciate, however, is that "deeper" and "further" are directional words: they imply the same direction as before, only beyond the current stopping point. This is a natural way for us to think, since even our tools are built on the foundation of what has been used previously.
So, what emerges is a picture of being emotionally committed to a certain way of viewing the question, the processes of answering it and the actual answers. And what if by narrowing ourselves to this one particular way of examining the world, to this one particular way to collect and interpret the evidence, we have effectively ignored all other possibilities?
Let me try to clarify what I mean a little further. We spend our days walking through waves. Some of these waves we can detect through our own senses: sound, light, for example. Others we need special external "receptors" to detect, such as radio and micro-waves. Is it possible that there are some other, heretofore unknown waves (or other phenomena) that are around us that we are unable to attune to because of our biology? Is it kooky to think that this is possible, or is it simply blind to walk away from such possibility?
The answer may be that it is both. Nevertheless, it is highly likely that there are many biological phenomena that are not amenable to being examined through our narrow prism of current methodology. We as scientists and clinicians need to be open to this possibility. The Buddha said that both preachers and scholars are blind because they constantly commit themselves to partially-seen truths. Given the shambles in which we find not only our nation's healthcare system, but also the health of its citizens, this would be a great time for this epiphany to penetrate our collective psyche and strive toward a broader view of possibilities. Let's give up the arrogance of ignorance in favor of the humbleness of enlightenment.
And these are my latest thoughts. I am not saying that they are the only way or that they are even remotely correct. But here they are nevertheless. Do with them what you will.
Tuesday, February 16, 2010
Buddhism and antibiotic resistance
There is a concept called "samatha" in Buddhist meditation. It has to do with sitting quietly, doing nothing. The opposite of mindless action, samatha is the cornerstone of the mindfulness practice. But what does it have to do with antibiotic resistance?
Well, I came across this interesting slide presentation by Dick Zoutman from Canada. Starting at the top of page 5, the talk goes into several fascinating surveys about what influences antibiotic prescribing for upper respiratory tract infections (URTIs). The first survey was of 316 family MDs in Ontario, which, among other factors, determined "physician's desire to act" as a risk factor for prescribing an antibiotic. The next survey of 313 patients identified patient expectation to receive antibiotic as the most important driver of prescribing behavior. The latter can be interpreted as a). the patient's preference for some kind of an action or b). the patient's expectation of action on the part of the MD. Either way, "action" is the operative word.
So, what does this mean? Well, at the simplest, most immediate level, this finding confirms that education of both physicians and patients is a potentially fruitful target for antibiotic stewardship programs. But at a deeper level, perhaps something as fundamental as a re-evaluation of our approach to life is what is needed. Antibiotic overprescribing is a clear example where the philosophy that doing something is better than doing nothing is not just wrong, but threatens to send us back to the dark age of pre-antibiotic era.
Western medicine in general promotes rapid decision-making as its paradigm. In fact, when I was in practice, there used to be tremendous political capital in the bravado of rapid assessment and planning. But let's not kid ourselves: the majority of treatment decisions made in the outpatient setting do not necessarily need to be rushed in the way that our expectations have driven them to be rushed. So, let's take this sage advice and "don't just do something, sit there". It is time for some samatha in our decision-making as both physicians and patients, lest we continue knee-jerking our way into this escalating resistance catastrophe.
Well, I came across this interesting slide presentation by Dick Zoutman from Canada. Starting at the top of page 5, the talk goes into several fascinating surveys about what influences antibiotic prescribing for upper respiratory tract infections (URTIs). The first survey was of 316 family MDs in Ontario, which, among other factors, determined "physician's desire to act" as a risk factor for prescribing an antibiotic. The next survey of 313 patients identified patient expectation to receive antibiotic as the most important driver of prescribing behavior. The latter can be interpreted as a). the patient's preference for some kind of an action or b). the patient's expectation of action on the part of the MD. Either way, "action" is the operative word.
So, what does this mean? Well, at the simplest, most immediate level, this finding confirms that education of both physicians and patients is a potentially fruitful target for antibiotic stewardship programs. But at a deeper level, perhaps something as fundamental as a re-evaluation of our approach to life is what is needed. Antibiotic overprescribing is a clear example where the philosophy that doing something is better than doing nothing is not just wrong, but threatens to send us back to the dark age of pre-antibiotic era.
Western medicine in general promotes rapid decision-making as its paradigm. In fact, when I was in practice, there used to be tremendous political capital in the bravado of rapid assessment and planning. But let's not kid ourselves: the majority of treatment decisions made in the outpatient setting do not necessarily need to be rushed in the way that our expectations have driven them to be rushed. So, let's take this sage advice and "don't just do something, sit there". It is time for some samatha in our decision-making as both physicians and patients, lest we continue knee-jerking our way into this escalating resistance catastrophe.
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