Monday, 26 September 2011

My way or the highway


When I first looked after stroke patients as a registrar in 2007, it was common not to artificially feed patients for up to a week. If a patient could eat, then we would let them eat, but often patients who have had strokes are unable to swallow food safely, and risk aspirating it into their lungs. These patients need to be fed via a feeding tube that goes down the nose, and while we would eventually get round to it, there was never any particular rush to put one in, because at the time there was no evidence that early feeding improved patients’ survival. The result, therefore, was that we became comfortable with patients being starved for days at a time before we arbitrarily decided when the right time to start feeding was.

Thankfully, some new NICE guidelines came out, encouraging stroke teams to start feeding patients within the first twenty four hours, and now it has become standard practice to start feeding patients as soon as it is practicable.

When I look back at the way we provided stroke care only four years ago, and compare how we do it now, it feels as though the past is a foreign country: we let patients starve, and literally used to tuck up our new stroke patients in bed until we could get a CT scan done. Now patients should have their head scan almost as soon as they arrive in hospital, and many are offered clot-busting medication, put on pressure-relieving mattresses to stop sores developing, fed, kept well hydrated and start their rehabilitation on their first morning in the stroke unit. Care has improved almost beyond measure, because a compelling case was made to offer stroke patients thrombolysis, and as part of the service re-organisation that providing this kind of care involves, it has been possible to improve every other aspect of stroke care.

There is a dangerous phrase that we throw around in medicine: ‘There is no evidence for that.’ Sometimes we are at risk of becoming hostages to the evidence base, and the example of stroke care that I give is a salutary lesson in just that. Empiricism is a powerful concept, and the idea that we should only use treatments that we are confident do more good than harm is one  I will defend resolutely, as it asks that we do not countenance treatments that are dangerous, and do not waste our money on treatments that do nothing. But the need for a good evidence base and randomised controlled trials have become cognitive short cuts, that interrupt original thought, and creative thinking. The shadow cast by empiricism over medicine is actually longer than it should be, and my argument today is that sometimes it can stifle creativity and stop us doing things we know are right.

For example, the absent of any positive statement that feeding someone in the first few days after a stroke stopped us doing so, and allowed us to become comfortable with starving patients. Common sense, I think, tells us, that in the absence of any other evidence, it is probably better to feed someone recovering from a serious illness than starve them.

Hand-washing is another good example - most hospitals now have a policy that clinical staff in clinical areas should roll up their sleeves and remove their watches, and all but their wedding rings. The fact that the latter is allowed is held up as an example of the lunacy of the ‘bare below the elbow policy’ as is the fact that there is ‘no evidence base for it’. But the more I think about it, the more I realise that it doesn’t matter if there is no evidence supporting this kind of behaviour - by rolling up one’s sleeves and removing most of our hand and wrist adornments, we make it easier to wash our hands properly. I agree that removing our wedding rings would make  it easier still, but the point is this: Bare Below the Elbow is common sense, and it also sends the message to our patients that our hand hygiene is something we take seriously.

I can’t remember what initially got me thinking about this subject, but I do know that I have found it really rather invigorating over the last couple of weeks to really challenge all the things I do without really thinking. Every day there are lots of examples doing things one particular way because that is the way we do them. Over the next week try asking yourself what it is you are doing and why. Is it because it is the right way or the best way, or is it because it is simply the way you have always done it?

We like to think that most of what we do in medicine is driven by good evidence and best practice, but having done this thought experiment for the last week, my experience is that my decisions and actions are often driven by my own personal experience, and what is practical.

I haven’t yet decided what to do with this realisation. Answers on a postcard please.

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