Wizard of Oz

June 8, 2008 at 7:10 pm | Posted in internship | Leave a comment

One of the more interesting things about medicine, considered on a broad scale, is its inherent conflict between precision and effectiveness. The kind of people who tend to choose medicine are compulsive about details, and in the overall care of a patient that’s a good thing. But in considering any particular detail of care, it drives me nuts how people get all worked up over things that simply don’t make a significant difference.

For example, why would I calculate a dose based on a population estimate of its pharmacokinetics, when individual variability is high, and I’m going to get a trough anyway and make changes based on the actual value regardless of what my calculation says it should have been. Particularly when my own eyeball estimate is likely to be just as accurate (or inaccurate) as any calculation.

And why, for the love of God, would I check an INR on day 1 of restarting someone’s coumadin, when it was a low dose that they were stable on before, and we’re not even bridging with heparin? Even an INR on day 2 is pretty useless, since there’s absolutely no reason it would shoot up dramatically, and if it’s low I’m not going to do anything about it anyway.

These things drive me crazy.

The details that were important in the first scenario were: 1. starting the drug for the appropriate indication, 2. getting a trough at the appropriate time, 3. setting the appropriate target for the trough.

In the second scenario, the important items were: 1. starting the drug for the appropriate indication, 2. the decision whether or not to bridge with an antithrombotic agent and/or add an antiplatelet agent, 3. ensuring appropriate followup.

Of course, it doesn’t help that I think pharmacokinetics is mostly voodoo–at least, as it applies to individual patients in a clinical setting. I mean, it’s certainly possible to predict the serum level of a drug based on patient-specific variables. And yes, I know how to do that. Or at least, I know exactly on what page of what book on my bookshelf the appropriate calculation can be found when I need it. The problem is, there’s no way to measure those variables reliably and accurately in an acute or critical care setting. So all you’re doing is hiding what is fundamentally a SWAG behind a bunch of scary calculus you hope no one else understands well enough to see through.

Maybe people don’t feel comfortable admitting that it’s just a guess, and they go through the motions to make themselves feel better. But whatever gene it is that lets people hide the truth from themselves like that, I just don’t have it.

Of course, there are places in medicine where it’s important to be very meticulous. Hemostasis in surgery. Anastomoses. Infection control.

And there are a whole host of details that can matter, or not, depending on the clinical status of an individual patient. And what I care about in a particular patient varies based on that. So it irritates me when people get nitpicky over the shibboleths of their field, without considering the whole picture.

I guess, if there’s anything that being an intern has taught me, it’s that there are lots of things that people care about, and few that really make a difference. And the things that matter are things that no one really connects to a good outcome, so if you screw it up, no one will ever blame you. It will just be ascribed to statistics, or patient disease.

But there are people who have statistically better outcomes than their patient population should support. So I try to pay close attention to what they do, and figure out how it differs from people whose outcomes aren’t as good. Particularly in neurosurgery, I watch what instruments people use, how they do various things, and what parts of the operation they take particular care with. And then I pay attention to what kind of problems the patients have postoperatively, and think back on any differences between that surgeon’s technique, or that particular operation, and other operations or other surgeons’ techniques.

Certainly I’m no expert on neurosurgical technique, but there are differences that even I can see between the ways that various surgeons will do the same operation. That, for me, has been the biggest benefit of doing away rotations. I’ve now seen a significant number of excellent neurosurgeons, doing a wide variety of operations. And although I never discuss it, I know I’m not anywhere near the first person to wonder about the link between the techniques used at a particular place and the kinds of complications that tend to be prevalent there.

Good outcomes are something I care a great deal about. But I want to figure out and get right the details that matter, and not get caught up in worrying about the ones that don’t.