Today, we were talking about hypoglycemia, and if you talk to people who finished their training only a few years ago and you'll hear the words, "Hyperglycemia doesn't kill anyone. Better to be high than low." This has been dogma until recently, when several nice studies have shown that poorly controlled glucose in critical patients increase mortality up to 15%. Now, the thinking is the opposite. I've actually told patients that hypoglycemia is the price you pay for good glucose control.
Then, there's pulmonary artery catheters. 4 years ago, this was a bread and butter procedure for internal medicine residents. Now, I don't know any resident that's done more than one. Looking a little further back, there's beta blockers in heart failure, the use of thrombolytics, stenting versus CABG, anti-TTG Ab versus duodenal biopsy.
My point is that medicine is a field of constant change, and not little change. Big change. Talk to a doctor 15 years ago, and if you told him that you thought that his heart failure patient didn't need a Swann and should be on a beta blocker, he'd accuse you of malpractice (and 15 years ago, he'd have been right!).
Some people like fields that are understandable and consistent. Medicine is not such a field. If the thought of continually keeping up with the changing world of medicine scares you, then you'd best stay away.
6 comments:
Compared to another field I was thinking of getting into when I was an undergrad—computer science and information technology—the rate of change in medicine is absolutely glacial. If you think about it, all those studies that support tight glucose control in critically-ill patients and beta-blockade during acute CHF exacerbations, that show PTCA is often as good as CABG, that Swan-Ganz catheters don't decrease mortality—these are all several years old and some are a decade old or more. Medicine is actually quite conservative, particularly when compared to basic science and engineering.
Well, there is constant change in most fields, but seldom a complete reversal of direction. For decades, the pulmonary artery catheter was something that nearly every ICU patient had. Now, I see one done maybe once or twice a month. That transition, which occurred before my eyes, was quite literally one month they were used, the next month, they weren't.
In my mind, the closest thing to such an about face would be the end of he 1.44 floppy disk.
Heh, re: Swans. That sounds like it was very attending dependent. At my program, in the two years I've been here, it seems like the pulmonologists never use Swans. The cardiologists will use them once in a while, especially when they want a cardiomyopathy patient's transplant status to be upgraded. Even if they stick one in, mostly all they care about are SvO2s anyway.
It's even worse. A recent survey found that 11% of consensus guidelines are outdated before being published, 40% are outdated in one year.
And that doesn't even go into the bias. Don't get me started.
I should note that it looks like the pendulum is swinging the other way on critically ill patients and glucose. Looks like high may actually be better than low. This is why I tell people not to look to this blog for medical advice.
"Benefits and Risks of Tight Glucose Control in Critically Ill Adults"
JAMA. 2008;300(8):933-944.
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