The Q-Wave: Dogma and Evidence-Based Medicine

John Bielinski, MS PA-C By December 19, 2019No Comments
The Q-Wave: Dogma and Evidence-Based Medicine

I just finished reading The Road Less Traveled by M. Scott Peck. It was a very powerful, psychological, spiritual book. I highly recommend it. In this book, Peck talked about an essential psychological change. He talked about this vital, spiritual experience we need to have if we want a personal relationship with God. Peck explains that you can’t really have a vital, spiritual experience by dogma. You can’t have a hand-me-down religion. You can’t be force-fed religion and expect to really know God.

That is absolutely my experience, and it really got me thinking about dogma. What does dogma mean in medicine? What does dogma mean in life? Steve Jobs, during his 2005 Stanford University Commencement address, said, “Your time is limited, so don’t waste it living someone else’s life. Don’t be trapped by dogma — which is living with the results of other people’s thinking.” That’s powerful to me.

In medicine, we love to use the term evidence-based medicine. Absolutely. Clearly, you have to follow evidence-based medicine. That’s how we legally know if we’re following a standard of care. How do we know to use aspirin when someone has an acute coronary syndrome? It’s because the studies show you save 21 lives out of a 100. That is overwhelmingly strong evidence saying, “You better use aspirin when someone’s having a heart attack.” That’s evidence-based medicine.

But what about dogma?

What about the things that people have told us over the years that really aren’t evidence-based, but instead just good pearls of practice? What about the things that I teach in my emergency medicine conferences that have helped my own practice tremendously?

I was just thinking about a colleague of mine who came into the emergency room with the face of a ghost on his day off. He came in, and he said, “John, I’m having chest pain.” I brought him into the room, and he was having an unstable angina event. He was sick. And I knew this guy; he was a nervous guy. I gave him a milligram of Ativan, because I knew he was nervous. That clearly isn’t evidence-based medicine, and it wasn’t a traditional standard of care.

I remember taking care of him after he got a stent. I asked him, “Is there anything you’ll do differently now that you’ve been a patient?” He said, “I’m going to use a lot more Ativan.” Because, he said, “It made me way calmer.” That’s not evidence-based medicine, but that is something I tried that had a good outcome.

Colleagues, I want to ask you, are you confusing fact with dogma in any area of your life? This Q-Wave newsletter is about clinicians trying to be better clinicians, and I want to ask, are you ever applying dogma without thinking it through? When we talk to patients, it’s very important that if we’re going to give someone our opinion, we need to clarify it.

As a provider, is there any evidence that makes us say, “Don’t eat seeds if you have diverticulosis?” The answer is no. It may be a reasonable recommendation, but we can’t sell something as evidence-based medicine if it’s not evidence-based medicine. We have a responsibility to know what the literature shows. We have resources now that you can check from your phone. You can check UpToDate in a matter of minutes to find out if there are literature-based recommendations.

As an educator, I have to be very vigilant about making sure my students know when I’m teaching evidence-based medicine and when I’m giving my opinion. I teach a mnemonic on chest pain called Who’s Your PAPPA? I say there are five causes of chest pain: Pericarditis, Acute Coronary Syndrome, Pneumothorax, Pulmonary Embolism, and an Aneurysm or a Thoracic Dissection. Clearly, there are a lot of causes of chest pain, but those are the big five. Those are the lethal ones that can really burn you. That’s not evidence-based medicine, but it is a valid way to approach to medicine.

Is there any value in dogma?

I think so. But we have to be critical in how we evaluate that content. We have to ask, “Does this work for me?” Peck, in The Road Less Traveled, said that a lot of us have a secondhand religion, one that was handed down to us that we don’t question. This hand-me-down religion doesn’t form a vital, spiritual experience.

If you read and interpreted the Bible for yourself, would you say, “Hey, this is the way to get to God!” Or would you just follow someone else’s thinking? Would you think to yourself, “Hey, someone told me to think this way and I’ve been taught not to question that thinking. I’m just going to do what they tell me to do.”

I do find a correlation between The Road Less Traveled and the practice of medicine. I feel medicine is a combination of dogma and evidence-based practice. In medicine, I take dogma to mean someone else sharing with me how they were successful in their role. And then, within that constraint, I need to practice evidence-based medicine.

Medicine is one of the last true apprenticeships. You need someone to show you how to read an EKG bedside when someone’s having chest pain. You can’t learn that from a textbook. That’s why PA school includes thousands of hours of rotations. Nurse practitioners have rotations; physicians have residencies. We have to be apprentices, so we can learn from practicing clinicians how they apply evidence-based medicine and their past experiences.

Thanks for reading this month’s Q-Wave. If this content helped you, please share it with others. Until you hear from us again, we’ll be getting ready for 2020. Colleagues, 2020 is very interesting, because it’s like 20/20 vision. We’re seeing things clearly. At CME4Life, we’re working very hard on seeing things clearly, in medicine and in life.

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