EBM That Gets You Side-Eye From Colleagues/ Staff?
My last shift I got a compliment from one of my nurses about how I’m always teaching them something that they didn’t even know existed or changed since they’ve been out of school, or that I do differently from other docs in the group but happily explain why.
Later on in the same shift, I overheard one of our crusty die-hard “Nurses are here to protect patients from providers” 20 year veteran nurses explaining to an orientee about how to protect themself and their license from my “refusal to address the patient’s emergently high blood pressure” before discharging them. Mildly irritating to say the least.
But the discrepancy in how different nurses (and even docs in the same group) will perceive the competency of the exact same doc based on nothing but historical dogma got me thinking about how we all have our own little demons sitting on our shoulder in every patient encounter, whispering conflicting advice about Evidence-vs-Experience-Based practices. And it made me think, “What are my practice patterns that stand out compared to the other docs in my group?” And a few that came to mind;
- Every infected kidney stone gets a call to urology.
- Medical patients don’t get intubated for low GCS outside of very niche circumstances. “Airway protection” is the general overlying indication for intubation, not a specific indication in itself.
- No gag reflex? Why did you check one?
- Headache is not a symptom of hypertension.
- Blood sugar level if not in DKA/ HHS and not in relation to another underlying issue such as infection or significant dehydration is irrelevant and doesn’t contribute to dispo.
- The number doesn’t matter for hypertension at discharge from the ED if not in hypertensive emergency.
- No A-Lines in the ED.
- Fevers don’t get stripped down, deprived of blankets, and externally cooled. In fact, fever is a distinct entity from hyperthermia.
- Rigors in the setting of an unidentified source of infection is bacteremia until proven otherwise.
- No plain films of the abdomen or spine.
- Every alcoholic gets full-dose Thiamine.
- Septic patients don’t get 30cc/kg unless hypotensive.
- I don’t perform stool occult blood testing.
There are more that I’m sure I’ll remember later, and I’m sure many of you see some of these and think “Well duh everyone knows that”, but if there’s anything my short career has taught me, it’s that there’s too much information out there to stay 100% up-to-date on every topic, so I’m also sure you also see some and say “Why?”. Which would be the TLDR of the post; I’m interested in hearing about your own strict Evidence-Based decision making that stands out from others in your group, and gets you constant questions or even pushback from others.