Wednesday, May 03, 2006

Knowledge

I just got back from the Pediatric Academic Societies meeting in San Francisco. It was a nice conference, with a good mix of both original research and review presentations. As a younger doc I used to come home from these conferences fired up about all the new and exciting things. Lately, though, I come home from them reminded more about how much we don't know rather than what we do know.

There's some pretty basic stuff we don't know. We don't know, for instance, when to transfuse babies with blood. We don't know whether giving sodium bicarbonate, a relatively common drug, does any good or not. (Well, actually we're pretty sure it doesn't do much good, but we use it anyway.) We don't know how to measure pain very well in premature babies or the best way to treat it. And if and when we do treat it, we don't know if that improves their overall outcome or not. We don't know the best way to treat low blood pressure in premies. We're not sure what the medicines used to treat low blood pressure do to the brain. For that matter, we don't really know what constitutes low blood pressure in the tiny premies, and like pain treatment, we don't know if treating it makes a difference in their long term outcome. I could go on and on about the stuff we don't know.

Sure, we often act like we know. (Parents don't like it if we don't.) For example, I could tell you at what point I treat low blood pressure in a small baby, and how I would treat it, but I'd be kidding both of us if I said I knew it made a difference for the better. Some neonatologists will tell you they do know when to treat low blood pressure and that they know it helps. Physicians with such bravado are probably the scariest docs of all, at least to me.

Don't be too discouraged by this. We've made some tremendous strides in improving the care of neonates. But for every question we've answered, it seems there are a dozen more still to be answered.

P.S. Grand Rounds is up at Polite Dissent.

14 Comments:

Blogger Flea said...

Don't know what you're doing? Primum non nocere

7:45 PM  
Blogger NeoNurseChic said...

Hrmm...my feeling after reading this is...So basically everything that we're doing, we have no proof that it has a beneficial effect compared to doing nothing at all? Frightening...really!

One of our attendings was on a flight back from the conference this afternoon, so I'm looking forward to hearing her (and the other docs) input or ideas for changes in the care we provide.

I think the latest change was possibly no more versed drips - although it wasn't a "set in stone" change by any means. Our director of neonatology brought it up in rounds a few weeks ago, and I know I have the article he referenced in my bag, but I haven't had time to read all the way through it yet.

Always interesting!

8:26 PM  
Anonymous Anonymous said...

How would you get proof? Can't very well do double-blind, placebo-controlled studies with newborns, let alone premature newborns!

Because life is so precious we can't do the very research we need to help preserve life. Ironic, no?

10:22 PM  
Blogger NeoNurseChic said...

Well, I don't know the specifics behind how they run, but there are units (at least one in NJ that I know of) that run on the principle of less is more. We received an infant from them once and heard a little about how the unit worked. Completely black at all times. Much less intervention. Allow the baby to have the "womb-like setting" as best as possible. I apologize for not knowing much more about it than that, however.

We do cluster care on our unit and provide a lot of developmental-oriented care, but it is definitely a different approach than what I just described.

I think our unit actually has at least two double-blind, placebo-controlled studies going on right now actually. However, still ethical and with the baby's best interest as #1 focus. Can't really get into it any more than that, though!

10:46 PM  
Blogger Dream Mom said...

Your comments don't surprise me at all. Sometimes, the more we know, the less we really know since we are forced to ask ourselves more questions. I think this is especially true for the preemies or even the infants. It has been my experience with Dear Son, that there is so much that we don't know when it comes to infants or even kids since the treatment and their response can be so different from the adults. I think this is especially true when it comes to pain! I distinctly remember when Dear Son was born many years ago, that most facilities didn't think infants "felt" pain! I can remember an article that was on the front page of the Chicago Tribune at that time where it talked about a study done of infants and they found that the ones who received anesthesia during open heart surgery performed better than those who didn't! Can you believe it!

I also can't tell you the number of times I heard a doctor say, "We really don't know." I have heard it a lot with Dear Son but I hear it the most with the smarter docs or the docs that see a lot more complex kids than the run of the mill, docs, so to speak. But that doesn't mean I don't have confidence in the physician. It just means that we are in a territory where no one has been before and we really "don't know". There just aren't many kids in the world with Dear Son's gene.

I agree with you 100%-it's the physicians who think they know it all, that are definitely the scariest!

12:03 AM  
Blogger Clark Bartram said...

One would think that just looking at the dramatic drop in the age of viability would be proof that we know what we are doing. But then a visit to the cerebral palsy clinic might just take the wind out of our sails.

12:04 AM  
Blogger That Girl said...

I also never mind when a doc says "I dont know". It makes me feel like he DOES know what he is doing because when you dont know but are cautiously trying, you are using your brain. When you "know" and it doesnt work I have to question your intelligence.

8:51 AM  
Anonymous Anonymous said...

i am proud to say that our unit considers pain to be a priority. In fact, pain is now considered to be the fifth vital sign.

Oh, yes - we can see when a premie is in pain. Its little vocal cords may not be as loud - but the heart beats faster, they pull as hard as their wee arms can pull, their mouths open in protest.

Sorry, this one is a pet peeve of mine.

i don't understand the myth (and i call it a myth) that we can't tell a premie is in pain.

Perhaps, because i am small. i am not a 6ft jock. You better bet you bottom dollar, just because i can't crush a pop can when i am in pain doesn't mean i am not in pain.

10:09 AM  
Blogger Kelly said...

I agree with That Girl.....it actually helps me to know when the doc "doesn't know", because then I don't have any preconceived ideas on how their handling things. It clears the air. It makes a doc look human, and that's an important thing. The "godcomplex" is not always in the patient's best interest. And putting it aside can show humility on the doc's part.

I can't tell you how good it felt to hear our ped neuro say, "I don't know as much about this issue as I'd like, so I'm gonna go study about it and call some colleagues so I can give you a good answer." He did that on a Sunday. Don't tell me that didn't bump him up a few points!

Kudos to Neonatal Doc for speaking openly on this subject!

12:00 PM  
Blogger neonataldoc said...

Thanks, everyone. It's good to hear some people say they don't mind when a doctor says "I don't know".
Anonymous, we actually can - and do - do studies in premies, and many of the best advances, like artificial surfactant, are the result of such studies.
Also, I didn't say premies don't feel pain. But we're kidding ourselves if we think that our pain scales are very good, or that we know the best way to pain.

8:27 PM  
Blogger CGI-angel said...

I agree,....that all doctors should flatout admit it if they dont know. Saves both their time and the patient's. I've seen specialists in the past where they obviously didnt know how to treat my problems....but yet kept telling me to go back and see them. I have much respect for the ones who tell me they're not sure and would rather refer me to someone else.

2:21 AM  
Anonymous MyssiAnn said...

I can't say that I love hearing that my doc or my kids "don't know", but I'd rather hear that if it's the truth. The scariest time I've heard it, my husband had e. coli and Dr. Hope (You have love a doctor named Hope, don't you?) told me he didn't know if he would live through it or not. His chances as a healthy 29 year old were better than average, but the average with the strain he had isn't very good. Hubby lived, but it took him a little over a year to feel really "well" again. His body took a beating those 10 days.
The least scary time I've heard it was when my son's ped said, "I don't know what I'm looking at, but I know who to send you to." We ended up at the developmental specialist who diagnosed my son's autism and sent a very specific treatment plan back to our regular ped. We've followed it and found out what did and didn't work and modified it as necessary and now our doc knows a lot more about autism than he used to know and my child is doing very well.
"I don't know" isn't a great answer, but it does start one asking questions, and in medicine, asking the questions can be the most important thing.

10:05 AM  
Anonymous Kim said...

So how did you like San Francisco?
The neurosurgeons were here recently, too. All my favorite bloggers are so close, yet so far... : D

I should visit the city more often, since I'm so darn close....

8:20 AM  
Blogger neonataldoc said...

Kim: San Francisco is great....

1:38 PM  

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