Obstetrics & Gynecology
|Medical Practice Design:
Timothy Bilash MD emphasizes patient care that does not cut corners and is shown to produce the most efficient and desirable clinical outcomes.
OBGYN is much more than primary care and demands the opportunity for expert informed personal dialogue between the physician and each patient. If you have unresolved medical issues or questions, consider making an appointment today. We promise you the most up-to-date care available.
Each of these steps increases diagnostic precision and treatment success. It is tempting to skip steps, change their order, or employ more expedient or less thorough means, often with predictably diminished effectiveness.
Labels: Labels help organize large amounts of information. But an over reliance on diagnostic labels oversimplifies diagnosis and treatment. Diseases are not static, patients with the same "label" are not all the same, and the label itself is not the disease.Labels help manage, not define patients.
Empirical Experience: Empiricism is practice founded on isolated (untested) experience, without the aid of science or a knowledge of principles. Personal empirical data is academically discounted because it is not generated by experimental randomized trials. "It is true because I know it" cetainly has limited validity in medicine, but practically it is applied more often than might be recognized.
Empirical Science: Although isolated experience is not adequate, empiric observations need not be unscientific. Therapeutics have been advanced by organizing these experiences as careful and controlled observations. Even when the mechanism of disease or drug interactions are not understood, controlled observational techniques (non-experimental) add to our knowledge and can apply broadly.
Scientific Experiment: Application of the scientific method to experimental therapeutics (tested by controlled experiment) is exemplified by a well-designed and well-executed clinical trial. It is the standard for evaluating therapies.
The cornerstone of any clinical trial is its controls. Many different types of controls may be used in a clinical trial, and the term controlled study is not synonymous with randomized study. Although the randomized, double-blind controlled trial is the most effective design for distributing bias and unknown variables between "treatment" and "control", it is not necessarily the optimal or applicable design for all studies. Randomized controlled trials often are not available.
Statistical Inference: Individuals have characteristics that can be grouped and analyzed. Population studies/ epidemiology can supplement experimentation, and is an important part of medicine that will be examined. It is in many ways a mathmatical extension of labeling and empirical experience, with advantages and limitations. Evidence-based Medicine is an extension of these statistical techniques to clinical inquiry.
Medical Therapy as Science: Even with the results of a valid clinical trial, the physician can at most develop a hypothesis about the effects of treatment. He cannot be sure that what occurred with other patients will occur with this one. In effect, the physician uses the results of clinical trials to establish an experiment in his own patient. An effect of a drug that is not seen in clinical trials may still be revealed in clinical practice. Determining that a drug causes unanticipated effects is one of the most important responsibilities of a physician.
Medical therapy is fundamentally based on the use of the scientific method. Therapy as a science does not apply only to the evaluation and testing of drugs. It applies with equal importance to the treatment of each patient as an individual. Therapists of every type have long recognized and acknowledged that individual patients show wide variation in response to the same drug or treatment.
The decision about the treatment is influenced by the accuracy of the clinical diagnosis and laboratory estimations of disease extent. There usually are insufficient data, either in the literature or from the clinical or laboratory profile of the patient, to indicate definitively the proper choice of therapy. The physician must treat using the best information available at the time. Subsequent adjustments are based on whether the regimen works.
As an example, drug plasma levels are useful as a guide, but not the sole determinant of dosing. The binding of drug to plasma proteins, alterations of partitioning of the drug between tissues and plasma, and changes in responsiveness to the drug by the target tissue alter therapeutic levels and require adjustment.
Recognition of beneficial and adverse drug effects requires a thorough knowledge of the intended as well as possible effects, a mental preparedness to appropriately connect events to the drug rather than to the disease or to chance, and on adequate observation of the patient.
"Every therapeutic plan is and should be treated as an experiment." This means that every doctor needs to be practiced in the scientific method.
[above adapted from Goodman and Gillman's The Pharmacological Basis of Therapeutics, 6th edition, page 40-47]
Newer information about decision making in the context of limited information (and limited time) is unfolding, which requires a re-examination of current ideas of medical practice. Malcolm Gladwell's Blink [2005, pages 107, 119, 122, 140, 141, 233] provides a look at this.
Over-scrutiny of autonomous practioners has an adverse effect on experts (excessive bureaucratic risk management review, for instance). "When you start becoming reflective about the process, it undermines your ability. You lose the flow. There are certain kinds of fluid, intuitive, non-verbal kinds of experience that are vulnerable to this process ... all these abilities are incredibly fragile." Verbal overshadowing can impair otherwise effortless abilities, while "allowing people to operate without having to explain themselves constantly ... enables rapid cognition."**
"When experts make decisions, they don't logically and systematically compare all available options. That is the way people are taught to make decisions, but in real life it is much too slow."
Algorithms are rules to protect the doctor from being swamped with too much information, not to restrict his/her decision making and authority.
And things that encourage accurate decisions are "skills that have been neglected by many training programs":
-be meticulous in talking to patients and listening to them
-give a very careful and thorough physical examination
Yet we overburden our nurses and doctors with reams of paper and uncountable numbers of computer screens. "When we make split-second decisions ... we are really vulnerable to being guided by our stereotypes and prejudices, even ones we may not necessarily endorse or believe." Awareness that ones performance will be scrutinized later makes that performance "even more biased".
In the long run, "successful decision making relies on a balance between deliberate and instinctive thinking ... in good decision making, frugality matters."
And then there is the scientific method. Is there some way to avoid sacrificing what we know works best?
|"What is called for is an exquisite balance between two conflicting needs: the most skeptical scrutiny of all hypotheses that are served up to us and at the same time a great openess to new ideas. If you are only skeptical, then no new ideas make it through to you. You never learn anything new. You become a crotchety old person convinced that nonsense is ruling the world. (There is, of course, much data to support you.)
On the other hand, if you are open to the point of gullibility ... then you cannot distinguish useful ideas from the worthless ones. If all ideas have equal validity then you are lost, because then, it seems to me, no ideas have any validity at all."
-Carl Sagan, "The Burden of Skepticism," Pasadena Lecture, 1987*