In medical practice, the words, “in my experience,” or “this is the way we have done it forever,” are scary.
Do these words imply an out of date doctor who fails to embrace the new, or is it really true that older less expensive therapy is still better–like Classic Coke. So much of medical dogma lingers on without any semblance of real confirmation.
Take as one of many examples, the use of beta-blockers in patients with lung disease like COPD (Chronic Obstructive Pulmonary Disease). Years ago, we were taught that beta-receptor blockade could exacerbate the wheezing of chronic lung disease. It was assumed that since beta-stimulation (think albuterol puffers) dilated the bronchial passages, beta-blockade must constrict the airways.
For decades, the many beneficial effects of beta-blockers were withheld from chronic lung patients due to this lingering dogma, devoid of any true scientific confirmation. I recently asked one of our most senior and respected pulmonary docs, “Dr Lâ€¦really how many times have you convincingly seen exacerbation of wheezing solely related to beta-blockers.”
“Maybe twice,” he responds. This in over thirty years of medical practice.
As a doctor of the heart rhythm, I am a believer in the value of beta-blockers. “In my experience,” I have seen no evidence that beta blockade exacerbates chronic lung disease. Period, not seen it. So, it was with great joy that I read a recent report (in a peer-reviewed journal) showing that, not only are beta blockers not harmful, but additionally, they confer significant benefit. A nicely done summary on Medpage is here.
Although this study is not a prospective randomized NEJM masterpiece, if taken in the context of real-life experiences, it confirms a clinical suspicion that beta blockers should not be dogmatically withheld from a cohort that stand to glean significant benefit.
In the case of lung disease and beta-blockers, the specific medical message is important, but the much larger story is: much of what we learn in medical school becomes woefully outdated and often proven downright wrong with time.
Consider that when I started medical school, beta-blockers were contra-indicated in weak hearts. Now, it is medical malpractice to not use them in weak hearts. Likewise, ACE inhibitors were thought to worsen kidney disease, now they are used to prevent the progression of kidney disease. Squishing blockages to make a coronary artery “look” less blocked was thought to prevent heart attacks. Now, it is known that squishing a blockage and inserting metal in close proximity to sticky blood may relieve chest pain, but does not lower the risk of heart attack or death.
Yes, some things in medicine stand the test of time. Listening to patients and really hearing their story (think syncope evaluation), meticulously collecting all relevant objective data, and discussing the pros, cons and alternatives of invasive procedures remain timeless strategies for success. Even more timeless is the ability to know when to unleash the fury of modern medical technology, and when not to.
Chronic lung disease patients share many features with heart disease patients. For example, both cardiac and lung disease cohorts are often burdened with a past history of smoking, atrial arrhythmias, high blood pressure, and hardening of the arteries. It is no surprise that beta-blockers, drugs with proven benefit in cardiac patients, would also benefit lung disease patients as well.
So the next time, a dinosaur-like, dogma wielding doctor admonishes me that lung disease precludes the use of beta-blockers, I will have more in my arsenal than words like, “in my experience.” I can cite this study and say, “ah, here is a study showing that beta-blockers do not worsen COPD, and can actually help the patient.”
“Where did you see that study,” they might ask.
I can say I learned of it from Twitter, and the blogosphere.
Gosh, things are different now: medical education drives onward with social media as a vehicle. It seems just yesterday, I was in the UCONN medical library looking up articles in Index Medicus, and then furiously blazing through supplies of nickels for the photocopy machine.
Now, I can learn on an elevator with an iphone.