Vital Times 2020 - 85

As David L. Sackett, MD, wrote in a landmark article
in BMJ,10 the unthinking application of evidencebased medicine may make it a " dangerous innovation,
perpetrated by the arrogant to serve cost-cutters
and suppress clinical freedom. " Instead, what it
should be is the integration of " the proficiency and
judgment that individual clinicians acquire through
clinical experience and clinical practice " and " the best
available external clinical evidence from systematic
research. "

Best Practice or 'Groupthink'?
Groupthink is defined as a phenomenon that occurs
when a group of individuals reaches a consensus
without critical reasoning or evaluation of the
consequences or alternatives.11 Unfortunately, " any
dissenters in the group who may attempt to introduce
a rational argument are pressured to come around
to the consensus and may even be censored. " This is
exactly what can happen when adherence to clinical
protocols becomes the benchmark of quality care.
Let's look at a real-life example. In the 1990s, we
were told that every patient with any risk factor for
coronary disease must receive perioperative betablockade, and compliance was measured as a quality
indicator. Unfortunately, much of the evidence behind
the recommendation was fraudulent.12 Upon further
investigation, aggressive perioperative beta-blockade
was associated with higher rates of hypotension
and stroke in the POISE trial.13 The eminent lead
author of many dubious articles cited as evidence for
aggressive beta-blockade-Don Poldermans, MD-
eventually was fired from his leadership positions.
Many of us didn't buy into the beta-blocker hype in
the first place. I can remember documenting the
administration of 1 mg of IV esmolol in noncardiac
cases so that the chart would be compliant with a
nonsensical dictum mandating a beta-blocker. Time
proved that resistance was the right call.

A similar argument can be made with regard to
antibiotic administration. Too often, a vague history
of penicillin allergy will lead the anesthesiologist
to withhold cefazolin, the indicated antibiotic for
prophylaxis in many cases, and give a drug with
a far worse safety profile, such as clindamycin
or ciprofloxacin. Cefazolin, unique among the
cephalosporin antibiotics, has no cross-reactivity with
penicillin.14 Yet when questioned about the choice,
the anesthesiologist's reply may be: " Well, that's what
the surgeon wanted. " That attitude automatically
establishes the surgeon as the boss and may lead
to a worse outcome for the patient.15 How is that
acceptable?

Trust Your Instincts and Be Kind
The feeling of powerlessness is thought to be a key
factor leading to physician burnout. Fortunately, we
are not powerless yet. Nothing is stopping us-at least
today-from exerting the clinical decision-making
ability we have as physicians. It's best never to make
a decision for fear of criticism after the fact. If the
case goes badly, you'll be criticized no matter what
you did. When it goes well, you'll know you made
the right call, even if few others know about it or
acknowledge it.
Be kind. Look, for example, at the protocols
for enhanced recovery after surgery. They
often recommend withholding benzodiazepine
premedication. But if your patient is facing surgery
that may be disfiguring or disabling, giving a
benzodiazepine may be the kindest thing you can do
for that patient. Trust your instincts and forget the
protocol.
Patients, in my personal experience, have described
prior awake fiber-optic intubations as " torture " and
" like being water-boarded. " Was that necessary?
Couldn't adequate sedation have been provided? With
today's video laryngoscopy equipment, unless the
patient has a full stomach and an unstable cervical

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Vital Times 2020

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