Wednesday, June 15, 2011

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!


  1. I agree fully with your sentiment that sticking with the herd is insufficient reason for justification of a practice pattern.
    I'm an ED doc in Canada and I feel fully supported by the evidence when I choose a rhythm control strategy for new onset symptomatic atrial fib.

    That being said....Atrial fibrillation, once it appears, is typically a chronic condition, though often paroxysmal and intermittent. Rhythm control is a strategy that maximizes patient comfort and minimizes time in atrial fib. However, there is not adequate proof that rhythm control in any form (including ablation) mitigates stroke risk to an extent that allows the patient to forgo anticoagulation.
    Rapid cardioversion is a strategy that maximizes patient comfort and allows management as an outpatient, both of which are preferable for most patients. These patients still require the appropriate investigations for new onset afib, and require risk stratification such as with CHADS2 or CHADS-VASC to determine stroke risk and anticoagulation strategy.

    Overall I think it is helpful to view atrial fibrillation as a chronic intermittent condition. Rhythm control is the aspect of management that maximizes patient comfort. Anticoagulation is an almost totally separate issue, and just because the sinus rhythm has been restored one should not assume that the stroke risk has changed.

    My 2 cents...Dr. J

  2. Dr. J.

    Thanks for reading! I fully agree with your points (and Dr. Mallon's salient points made in the debate). Rate vs rhythm always seems to point to rate control for long term benefits. My concern isn't so much about the topic at hand so much as the overall sentiment "don't deviate from what others do" stifles innovation and improvement in practice. Medical information is growing in leaps and bounds and on average, it takes 20 years for an intervention of benefit to be widely practiced. Take therapeutic hypothermia as an example. NNT of 6 yet still not as widely available as it should be. My greatest fear is that if we continue to always stick with the herd, we'll never get "better."

  3. Rob, I totally agree with your main point. I was just being nit-picky about the idea of sparing the patient coumadin.
    I think that web 2.0 and rapid uptake by emergency docs has fundamentally changed the idea of peer based practice patterns, and time to uptake of new research in the ED. These days there is no reason that any ED Doc in any sort of practice can't be cutting edge, up to date and making their own critical evaluation of new research and ideas as they emerge. The idea of following the crowd is very last century, but remember that Mallon et. al. are the folks who set the practice standard and lead the herd before web 2.0 in essence democratized the conversation in EM.

  4. Aaron, I assume you're Dr. J as well ;-) I'm constantly humbled by the amount of information available to us via web 2.0 technologies. I also love listening to Dr. Mallon. While I haven't met him, I've watched him speak at ACEP and listened to his lectures via emedhome. He certainly has a way of stirring up a controversy at times.

    I think it's important that we (as scientists) don't always agree on the design of studies, number used, outcomes measured, etc. I think you hit a key point in your last comment; "making their own critical evaluation." The debate that my post was lifted from was done before an audience of residents and students. I see the comment as an eminent teacher (in this case Dr. Mallon but could it be anyone with authority) making the critical evaluation for the learners without them having taken the time to learn and see for themselves. They're now practicing "eminence based medicine" instead of evidence based medicine. I also think we all fall into this trap. Dr. Newman of is constantly reminding me that I have only scratched the surface of the literature. After pulling some of the referenced studies that they discuss, I begin to feel fairly ignorant in the care of my patients. Medicine demands constant evaluation and improvement and even with web 2.0 it is impossible to stay abreast of all the latest and greatest knowledge.

    Thanks again for reading. It's been fun to toss this around and delve deeper.

  5. you just raised some valuable points and post a good amount of informative content. yeah i agree with most of the points. I will definitely bookmark your blog for future reference. Kee sharing!

  6. Wow, thanks for sharing such an interesting and enlightening post. I think it is a kind of motivation to new interns too. Every medical student should read and follow.