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ResearchBlogging.orgOne of the frequent complaints I hear about science-based medicine is that it is dangerous.  Of course, it’s true—so is riding in a train, but it sure beats walking.  And that’s the danger of this particular fallacy—yes, medicine is a sharp tool, but it’s also an effective tool, so we must use it properly.  And this is where the tools of evidence- and science-based medicine can give us a hand.

The potential harms of modern medicine must be approached carefully.  If they are ignored or approached in an ineffective way, we’ll miss an opportunity to save lives.  This comment from my other blog is typical:

You asked if so-called traditional Chinese medicine has ever eradicated any diseases. Well, yes. It pretty much eradicated one that is in epidemic numbers in the U.S. and most of the developed world: Iatrogenic disease.

This is wrong is so many ways.  The definition of “iatrogenic” is difficult.  The traditional definition is “adverse effects of medical treatment or advice.”  I suppose one could broaden this to include failure to give proper advice, as inaction by a physician has similar consequences to action, but perhaps that is a discussion for another day.

The way in which this is truly wrong is the false dichotomy. Yes, medical errors would be reduced to zero if we didn’t treat people, but the consequences would be rather dramatic.  Our goal should not be to abandon modern medicine because it sometimes causes harm.  Our goal is to reduce iatrogenic illness in a science-based way.

Strangely enough, this is being done.  A recent study in the New England Journal of Medicine (effectively discussed here) described a study in which surgical checklists reduced errors.  This study was based on earlier work by Peter Provonost of Johns Hopkins, the subject of a terrific piece in the New Yorker.  (Related commentary here.)

The basic idea is this:  intravenous  catheters in intensive care units (ICUs) often become infected.  While they are necessary for the delivery of medications and the monitoring of hemodynamic parameters, infections can be devastating.  This study made use of a large number of ICU beds (including 85% of ICU beds in my home state).  The project, called “Keystone”, asked the ICU staff to do one simple thing (emphasis mine):

The study intervention targeted clinicians’ use of five evidence-based procedures recommended by the CDC and identified as having the greatest effect on the rate of catheter-related bloodstream infection and the lowest barriers to implementation.1 The recommended procedures are hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters.

Strategies to increase the use of these procedures have been described elsewhere.10 Briefly, clinicians were educated about practices to control infection and harm resulting from catheter-related bloodstream infections, a central-line cart with necessary supplies was created, a checklist was used to ensure adherence to infection-control practices, providers were stopped (in nonemergency situations) if these practices were not being followed, the removal of catheters was discussed at daily rounds, and the teams received feedback regarding the number and rates of catheter-related bloodstream infection at monthly and quarterly meetings, respectively. In April 2004, a letter and a baseline survey were sent to the chief executive officers (CEOs) of the participating hospitals. The letter outlined the evidence supporting the use of chlorhexidine1 and asked the CEOs to stock chlorhexidine in their hospitals before implementing the study intervention.

A checklist was used.  Supplies were provided. Non-emergent procedures were stopped if procedures weren’t followed.  And a checklist was used.

So what happened?

The baseline rate of catheter-related infections was about 2.7/1000 catheter days.  After implementation, the rate was zero.

Yes, zero.

One particular serious iatrogenic illness was effectively eradicated by a simple, easy-to-implement intervention.   My earlier commenter was correct; if we stop using modern medicine, we will have no iatrogenic disease.  We also will be left with a much sicker populace and a lower age of mortality.  It turns out we have a third path—use science-based medicine to solve the problem of iatrogenesis.  Not all problems will be solved so well as this one—there will always be some non-zero rate of serious medical complications, but as this study shows, it doesn’t always take a whole lot to make a big difference.

References

Peter Pronovost, M.D., Ph.D., Dale Needham, M.D., Ph.D., Sean Berenholtz, M.D., David Sinopoli, M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara Cosgrove, M.D., Bryan Sexton, Ph.D., Robert Hyzy, M.D., Robert Welsh, M.D., Gary Roth, M.D., Joseph Bander, M.D. (2006). An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU New England Journal of Medicine, 355 (26), 2725-2732

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  • Peter A. Lipson, MD is a practicing internist and teaching physician in Southeast Michigan.  After graduating from Rush Medical College in Chicago, he completed his Internal Medicine residency at Northwestern Memorial Hospital. He currently maintains a private practice, and serves as a teaching physician at a large community hospital He also maintains appointments as a Clinical Assistant Professor of Medicine at Wayne State University School of Medicine and at Oakland University William Beaumont School of Medicine, the first being a large, established medical school, the latter being a newly-formed medical school which will soon be accepting its first class of students.  He blogs at White Coat Underground at the Scientopia blog network. A primary goal of his writing is to illuminate the differences between science-based medicine and everything else.  His perspective as a primary care physician and his daily interaction with real patients gives him what he hopes is special insight into the current "De-lightenment" in medicine.  As new media evolve, pseudo-scientific, deceptive, and immoral health practices become more and more available to patients, making his job all that much more difficult---and all that much more interesting. Disclaimer: The views in all of of Dr. Lipson's writing are his alone.  They do not represent in any way his practice, hospital, employers, or anyone else. Any medical information is general and should not be applied to specific personal medical decisions.  Any medical questions should be directed to your personal physician.  Dr. Lipson will not answer any specific medical questions, and any emails and comments should be assumed public. Dr. Lipson receives no compensation for his writing. Dr. Lipson's posts for Science-Based Medicine are archived here.

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Posted by Peter Lipson

Peter A. Lipson, MD is a practicing internist and teaching physician in Southeast Michigan.  After graduating from Rush Medical College in Chicago, he completed his Internal Medicine residency at Northwestern Memorial Hospital. He currently maintains a private practice, and serves as a teaching physician at a large community hospital He also maintains appointments as a Clinical Assistant Professor of Medicine at Wayne State University School of Medicine and at Oakland University William Beaumont School of Medicine, the first being a large, established medical school, the latter being a newly-formed medical school which will soon be accepting its first class of students.  He blogs at White Coat Underground at the Scientopia blog network. A primary goal of his writing is to illuminate the differences between science-based medicine and everything else.  His perspective as a primary care physician and his daily interaction with real patients gives him what he hopes is special insight into the current "De-lightenment" in medicine.  As new media evolve, pseudo-scientific, deceptive, and immoral health practices become more and more available to patients, making his job all that much more difficult---and all that much more interesting. Disclaimer: The views in all of of Dr. Lipson's writing are his alone.  They do not represent in any way his practice, hospital, employers, or anyone else. Any medical information is general and should not be applied to specific personal medical decisions.  Any medical questions should be directed to your personal physician.  Dr. Lipson will not answer any specific medical questions, and any emails and comments should be assumed public. Dr. Lipson receives no compensation for his writing. Dr. Lipson's posts for Science-Based Medicine are archived here.

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