The medical literature slowly becomes outdated. As a result there are not that many ‘classics’ in the field, since their content is becomes less relevant. The medical aphorism is that 10 years after graduation from medical school, half of everything you learned will no longer be valid. The problem for medical students is trying to figure out which half of their curriculum is not worth learning.
Old studies become increasingly irrelevant as diagnosis and treatment changes over time under the relentless pressure of medicine. I once came across the best of Osler, with his descriptions of typhoid fever and pneumococcal pneumonia. The essays were far more literary in style than todays journal articles, describing the presentation of these diseases in Dickens’ like detail, but of little practical help given the advances in treatment and the understanding of microbiology of diseases.
Technology also expands and limits what papers are available. If there is not an electronic form of an article, it might as well not exist. Many classic articles are not yet available in digital form, and the article in question for this post I had to get as a scanned version of the original paper, rather than a pdf. As a result of time and lack of electronic access, much of the older medical literature is not easily accessible, and journal publishers are not particularly interested in the free dissemination of information. Which is a shame. There is the occasional older references that is as applicable today as when it was published.
There was never, to the best of my recollection, a time when I was not a skeptic. But there was a time when I had neither the time nor the knowledge to be able to think skeptically about medicine. The torrent of information that needs to be assimilated in medical school, residency and the first part of fellowship makes reflection about that information almost impossible.
I do remember an article that was a turning point in my thinking about thinking about the practice of medicine. It was 1989 and the last year of my Fellowship and was published in the American Journal of Medicine, entitled “Observations on spiraling empiricism: its causes, allure, and perils, with particular reference to antibiotic therapy” by Kim and Gallis (hence forth called OOSE, pronounced, I suppose).
If you can scrounge up a copy, by all means do so, as it is a classic. It is a collection of logical fallacies and critical thinking as applied to infectious diseases. It was the first time I read an article that discussed how to think about thinking in medicine. I had no idea that there were logical fallacies. Most of what passed for critical thinking in my training concerned understanding the statistics and the materials & methods of studies. Important, but limited.
OOSE starts with a description of the discovery of antibiotics and the amazement of physicians that for the first time diseases that were often fatal were now curable. It must have been an amazing time for physicians when infections that routinely killed were suddenly vanquished. I have witnessed a similar revolution with the advent of HAART, where AIDS has gone from a 9 month life expectancy to a chronic disease with perhaps a normal life expectancy. At my hospital is Dr. Charles Grossman, now in his 90′s and still attending conferences. His long and productive medical career started at Boston Hospital where, as an intern, he was involved in giving the first iv dose of penicillin to a lady who was dying of a streptococcal infection, who survived another 50 years (2).
Antibiotics have been developed to kill increasingly resistant and virulent bacteria, and until recently we have managed to keep one step ahead of the organisms. Unfortunately, the ability to become resistant is outstripping out ability to develop new agents and we are slowly, and inexorably, losing the battle, sliding in to the post antibiotic era.
Part of the evolution of resistance occurs from the inappropriate use antibiotics, which can often be due to uncertainly of the diagnosis. But inappropriate antibiotic use can also due to faulty thinking.
As the authors of OOSE note, “The imprecision of clinical practice establishes context, the litigious nature of our society unnerves; the absence of toxicity permits; and the sum of these encourages the incontinent, extemporaneous use of these antimicrobial agent.”
Incontinent use of antibiotics leads to increasing bacterial resistance,and the use of antibiotics when they have not been needed has accelerated the evolution of pathogens, occasionally to the point where there are infections I cannot cure and bacteria that I cannot kill.
“The term spiraling empiricism describes the inappropriate treatment, or the unjustifiable escalation of treatment, of suspected but undocumented infectious diseases. Empiricism and empirical therapy, defined as the carefully considered, presumptive treatment of disease prior to the establishment of a diagnosis, often are necessary in the proper practice of medicine. On the other hand, ill-considered or inappropriate use of antibiotics, incurring unnecessary risk and expense, should be indicted and condemned, The difficulty like in distinguishing reasonable or appropriate from unreasonable or inappropriate therapy.”
As a teaching physician in a teaching hospital, I notice that sometimes it is the FUD, Fear Uncertainty and Doubt, combined with faulty thinking that sometimes leads to the inappropriate use of antibiotics.
OOSE provide a conceptual framework for approaching diseases and potential therapy (see table below); Observation, prophylaxis, empirical, therapeutic trial, and specific therapy. Of these, the first and the last, are, sadly, the least used. For interns and resident, the motto is ‘Don’t just stand there, do something’, and with the pressures to shorten hospital stay as much as possible, simply watching the patient is a luxury few can afford. As an experienced physician, I feel much more comfortable with the motto, ‘Don’t just do something, stand there’, or as the paper calls it “masterly inactivity.” As my wife can attest, I am the master of doing nothing.
Specific therapy in infectious diseases is not as common as I would like given the vagaries of growing the infecting organisms and the degree to which one wants to maximize diagnostic certainty. I could probably get the etiology of every pneumonia admitted to the hospital with an open lung biopsy, but it would hardly be worth the resultant morbidity and mortality.
Most of the time the patient is ill enough to be admitted to the hospital and, after appropriate studies and cultures are done, empiric therapy is started. That is often not an unreasonable course of action. These days you have to be ill to get admitted and it is the rare patient who comes into the hospital who can wait for cultures to be positive before beginning antibiotics. I cannot emphasize enough how ill patients are when they are admitted to the hospital, and how unclear the proper diagnosis can be at the beginning of a hospitalization. After a day or two all the diagnostic information has returned and the, with the 20:20 vision of hindsight, the correct diagnosis may become clear and as a result the proper course of therapy is clarified.
Since cultures are often negative, the empiric course of therapy may morphs into a therapeutic trial.
After setting the therapeutic framework in place, OOSE proceeds, with case reports, to describe fallacies in antibiotic therapy that lead to the wrong therapeutic interventions. There is, in medicine, a long tradition of using cases as illustrative of problems, but not as anecdotal evidence for the proof of a hypothesis. We all remember concepts when they are applied to specific patients and specific cases.
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