Should we trust experience, or knowledge?
Have you ever thought about how physicians practice differently today compared to just a few decades ago?
I’m a 2010 med school graduate so my perspective on physician practice is biased by modern training. However, I, like many others, was trained by attendings that spanned several generations. So I often got glimpses into how medicine might have been practiced 10, 20, or 30 years ago.
While I can’t speak from personal experience, I often got the impression that the farther back you go the wilder medical practice was: residents having less oversight, young residents almost independently running ICUs, less consensus about how to approach a certain problem, more personal preference in clinical practice, etc. In my head it was the wild west of medicine. That’s probably not entirely accurate but ask any older physician and I think they’d quickly agree it was definitely less regimented “back in the day”.
This evolution matters because it has changed how clinicians talk to each other about medicine and how they make medical decisions.
Let’s take an example, but first some brief clinical background for non-clinical readers: In anesthesiology there is a common procedure (the spinal) that’s used to provide anesthesia for C-Sections (and some other procedures). To do that procedure we place a spinal needle into the space containing the CSF and inject local anesthetic. An image to illustrate:
Post-spinal headaches are a potential risk so it’s natural to ask if there is anything we can do to reduce that risk (such as using one type of needle over another). I imagine that if this question were asked of a doc 40 years ago and a modern graduate we’d get two different answers. Let’s imagine how that conversation might go:
Question: Is a pencil point needle better than a quincke needle for spinals?
Answer from a doc from many generations ago: In my practice I like the feel from a quincke needle better than a pencil point needle so I tend to use it frequently. But in discussions with colleagues there seems to be less PDP headache with pencil point needles so I use that when I can.
Answer from a new graduate: Evidence indicates a lower rate, by several percentage points, in PDP headache with pencil point needles versus cutting needles. And it is a statistically significant difference. So, we’re taught to use a pencil point needle, which is my practice.
With the older doc, practice leads to evidence. With the newer doc, evidence leads to practice.
In fact, it is universally taught to anesthesia residents that “pencil point” needles lower the risk of post spinal headaches when compared to “quincke” needles. And there is evidence to support this.
But, with this modern transition to evidence based medicine we’re at risk of losing something very important. Again, let’s look at an example: While training I once struggled with a difficult spinal. My older experienced supervising attending handed me a quincke needle and said, “use this needle instead of the pencil point”. When I asked why, she said, “you get better feedback with this type of needle”, meaning I’d be more likely to get the needle in the right spot and successfully complete the procedure.
I never thought of that possible difference because no one ever talked about literature that related to the “feel” of the different types of needles (also, it is hard to have evidence for this topic because it might never be studied and it’s an inherently subjective topic). Furthermore, because a pencil point was the “best” choice, it’s all I ever used and so I had no personal experience to prompt me to try an alternative.
So, if asking the the above question, “Is a pencil point needle better than a quincke needle for spinals?”, the best answer might be to show what the evidence says, but qualify it with subjective experience that might prove useful one day. This is why a curbside is valuable…because it can give both sides of the story.
And in fact it may help address inconsistencies in practice: While in training I helped a colleague with a lumbar puncture that she was struggling with (technically a very similar procedure to a spinal). The procedure kit she handed me had a quincke spinal needle. As far as I could tell it was (and is) common for lumbar puncture kits to contain this needle despite common teaching in anesthesia that pencil point needles come with lower headache risks.
Inconsistencies across specialties might diminish with better sharing of information. Literature tends to be segregated between specialities because we have different journals, conferences and practices. So venues that encourage cross talk have obvious benefits. The curbside is classically that venue and just needs to be modernized for today’s challenges and requirements.
The conclusion is simple: get the evidence and facts, but don’t ignore wisdom and experience. If we can do that on MedCurbside, we can make medicine better.