Stick with the Herd?

Knowing is not enough.  We must apply.

-Johann Wolfgang von Goethe

My daily commute to work takes me through the hills of western Pennsylvania.  It takes me 40 minutes to make the trip so I've really come to love podcast and audio based education.  Mel Herbert and the crew at EMRAP do a great job of putting on a quality show.  

Recently, the crew recorded a debate between Mel and Billy Mallon about the Ottawa Aggressive Protocol for Atrial Fibrillation.   During his rant, Dr, Mallon makes some important criticisms of the protocol.  If he had stuck with his numbers, he would have made a convincing argument against the protocol.  But then, he blunders.  As an educator, he makes a statement to his residents and students that I see as irresponsible of an educator.

It goes as follows:

"My top 10 reasons for not doing this are: 1. Most don't.  And just as an idea in medicine and a concept: stay within the herd.  If you want to know what the problems are of not being in the herd, turn on the nature channel.  The gazelles that are not in the herd, are lion food.  Okay?  Stay with the herd!  The herd doesn't do this."

Really?  REALLY?  An idea and concept?  That's the number 1 reason?  Do what everyone else does?  That sounds more like lawyer speak than physician speak.  Almost like when I overheard a fellow faculty member tell a resident to get ankle x-rays on a Ottawa negative patient "because this isn't Canada; Canadians don't get sued."

The "go with the herd" mentality is a dangerous preposition in medicine.  Medical history is filled with vivid examples of how patients were harmed because the this mentality.  Virchow, the leading authority in his time, was particularly critical of Ignaz Semmelweis and his data to suggest that physicians could cut disease rates by simply washing their hands.  Who knows how many lives were lost due to the fact that physicians were "gentlemen" and felt that they didn't need to wash their hands.  160 years later, we're still dealing with the fallout.

Why is it that interventions known to be effective take so long to put into practice.  Herd mentality.  If nobody else does it why should I?  There is an old joke in medicine that you don't want to be the first to do something.  But, you also don't want to be the last.  

As educators, we have a responsibility to be second or third.  We need to be early adopters and try out new ways of taking care of patients especially when the literature shows some support.  We need to take what others have done and reproduce it, testing it with our learners and demonstrating that science constantly changes.  Even more, we need to measure our results and disseminate them with time.  Only then can we advance the care of our patients.

Take the Ottawa Protocol, for example.  I've used it for 4 patients now with a 75% success rate.  To be fair, I haven't sent the patients home.  We don't have the most reliable outpatient followup.  That being said I've managed to admit patients to beds without the need to advanced monitoring since they didn't need vaso-active drips and have kept them off of the nastiest of nasty drugs, warfarin.  

And that is only one example of a countless list.  The last 2 decades have shed light on the failure of medicine to adopt treatments that benefit society.  We have become far more capable of creating knowledge than using it.  Perhaps our fear of leaving the herd is partially responsible for this failure.  

So lets change it.  Let's take the time to venture outward, leading the herd.  Let's generate knowledge and take time to test it, apply it, and teach it.  

What of the risks?  Remember, when you lead the herd, you don't need to outrun the fastest lion, only the slowest gazelle.  You're never alone out there!