Hole-ier than Thou, Evidence Based Regardless of the Evidence

evidence based medicine

by Dr. Michael Miller

There are certain phrases that make the hair on the back of my neck stand up.  Someone telling me that they are a good Jew, a good Christian, a good Muslim or the ultimate in self serving lies, “I ONLY practice EVIDENCE BASED MEDICINE”.  People who are what they claim they are do not need to announce it.  A short conversation, watching them work, others opinions about them all answer the question before it is asked.  Like the RN who asked for a recent presentation on the true science behind NPWT (no, you don’t really understand it).  She made sure to tell me not only that she practiced only EVIDENCE BASED MEDICINE but then gave me several examples which incidentally had absolutely no scientific evidence (save for articles from lots of dabblers doing lots of crazy things to people and writing about them).  I am now awaiting her response as she may have to realize that her version of EVIDENCE BASED is no more real than Kim Kardashian’s celebrity.

More humorous to me was finding out the effect of several of the challenges I made to a conference audience regarding certain aspects of their care that have no basis in science and in fact have support diametrically opposed.  Apparently, several highly educated, professional, ethical audience members were so shaken from their pedestals, that they told the conference directors I had told them some things that they had not heard before and they weren’t sure they liked that.   Imagine going to a conference with the expectation that your care is perfect and that your goal is to make sure there is universal homogeneity…with your care.  My goal has always been to drag people to the dark side of logical, best care away from the soft warm bosom of “I’ve always done it that way” .  My response was a simple apology to the conference heads for making people think about mundane things like not hurting patients, not spending money stupidly and not daring people to do better care.  They laughed.

I respectfully request that someone explain to me why long term care facilities refuse to accept help when so desperately needed ?  In our area, we have a large number of facilities that never have any bedsores until he patient goes home and home health care requests emergency consultations.  A call to the LTC regarding an offer of help always is met with their infatuation with their primary care medical director who has no wound care training led by a newly ordained wound care nurse whose knowledge came from the recent issue of the facility journals.  The same goes for many Home health care agencies all of which advertise that “We do wound care”.  Of course, the real skill required to do a well applied, weekly 4 layer venous compression system versus their usual telfa island wrapped loosely with gauze daily would be like making Steven Hawking create a time travel machine using Legos.  The only people happy about this seem to be the attorneys whose business (even in Indiana with a great system for liability protection) is booming.  Is it pride, is it fear of someone finding out that you are having problems, is it the egos of the primary care docs for whom a world without antibiotics would be equivalent to a 4 extremity self amputation?

And I am not merely talking about “simple” bedsores or skin tears.  Like the combined venous/ lymphedema patient of mine who’s noncompliance at home mandated long term care placement.   At over 400 pounds with multiple massively weeping leg wounds, the facility doc refused my help because he could not work with one of those wound care centers.  Sadly the patient has improved with absolute bedrest and oragami-like elastic wraps at the expense of his ability to walk.  Never mind the pathophysiology of the disease, the ultimate toll it will take on his ability to self care and the unquestionable recurrence, that doc’s conscience won’t bother him as long as that patient leaves “better”, never to return.  His motto must be, it’s only illegal if you get caught.

Evidence is a term identifying some form of support, verification or  confirmation.  Success of a given action does not mandate continuation ad infinitum nor does failure assure condemnation.  We travel the care spectrum from a Gold Standard for a given problem to Perfection for all of them.   The goal is to logically, ethically and humanely recognize that each patient is different and each of their wounds also different. Continuation of any practice merely because “We’ve always done it that way” or clinging vainly to beliefs or practice long past their vintage is itself evidence that something is missing in your care.  Don’t believe me?  I’ve got the evidence here somewhere.

Until we ramble again.

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Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, Wound Care Advisor. All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

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