SGEM#49: Five Stages of Evidence Based Medicine Grief

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Date: October 18, 2013

Guest Skeptic: Dr. Jeremy Faust (EM resident Mt. Sinai Hospital, New York City)

Every few episodes I like to take a 10,000 foot view of evidence based medicine (EBM). It is fun to switch gears from the typical critical reviews of random clinical trials or systematic reviews normally covered on TheSGEM. An opportunity to think about the big picture. Not to get lost in statistics of likelihood ratios, confidence intervals, NNTs and bootstrapping.

Jeremy Faust is a self described EBM zealot. He writes a column in ACEP News on the topic of social media. Jeremy wrote one article on EBM and the Five Stages of Grief which caught my eye. So while attending the American College of Emergency Physicians (ACEP 2013) meeting in Seattle, I asked Jeremy to be a guest skeptic.

Case Scenario: Well respected EM attending recommends using epinephrine for an unwitnessed, out of hospital cardiac arrest in an adult patient.

Background: The five stages of grief as originally described by Kubler-Ross in 1969 in the book On Death and Dying. The five stages are: Denial, Anger, Bargaining, Depression and Acceptance. People do not experience these in order, there may be other stages and not all stages need to be experienced.

This podcast discusses the five stages of grief using a number of medical studies as examples.

Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest. NJEM. Dr. Ian Steill
Tissue plasminogen activator for acute ischemic stroke. NEJM. NINDS
Third International Stroke Trial. IST3. Lancet. See SGEM#29
Parachute Trial. Smith and Pell. BMJ.

Winston Churchill said “democracy is the worst form of government except all the others that have been tried.” This is how I feel about EBM. It is the worst form of medicine except for all the other that have been tried.

Or for the American SGEM audience a quote from JFK on democracy: “Democracy is difficult kind of government. It requires the highest qualities of self discipline, restraint, a willingness to make commitments and sacrifices for the general interest and it also requires knowledge”. Freedom has many difficulties and democracy is not perfect”

EBM is a difficult kind of practice. It requires the highest qualities of self discipline, restraint, a willingness to make commitments and sacrifices for the general interest and it also requires us to choose wisely. EBM has many difficulties and it is not perfect. Do we really want to go back to blood letting patients and mesmerizing them with magnets?

We hope this helps you address those friends experiencing the five stages of EBM grief.

Keener Kontest: Last weeks winner was Ben Williams from Nanaimo BC. He knew that the Ottawa Ankle Rules (oops) TOOLS have been validated in children as young as FIVE years old (SGEM#3). Congratulations and I will be sending you a cool skeptical prize.

Listen to this weeks episode of TheSGEM for the keener kontest question. Send me your answer to TheSGEM@gmail.com. Be the first one to answer correctly to win a skeptical prize.

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