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Monday, March 22, 2010

Making and Breaking Rules

A couple of weeks ago I posted on neonatal hypertension. In the course of that piece I commented that I had made a rule about when I would recommend treatment for this condition. A commenter, Dr. Isis, asked the following:

I am interested in the "I decided to make a rule..." part of it. Can you tell us more about how you made this decision?

I posted an answer about my review of the literature and other considerations, but that really does not address the root of the issue; why did I feel the need to make a rule?

So I reviewed a relatively recent book, How Doctors Think.HowDrThink This read from 2007 examines the ways physicians deal with uncertainty in medicine. We learn to recognize patterns, and respond to them accordingly. Neonatal hypertension bothered me because of the uncertainty, the lack of data to drive decisions. We usually cannot identify a cause, we cannot determine which tiny minority of patients will not do well, and yet we hope to do no harm using drugs not approved for use in infancy.

In my case, I wanted a rational approach to the common neonatal hypertension patient who had no evidence of kidney or vascular problems to explain the hypertension. I picked a level of blood pressure that seemed significant, and I decided to treat at that level.

Physicians deal with uncertainty on a daily basis. We rarely know everything about a patient (not until the autopsy, anyway), and our patients rarely fit the textbook completely. Recognizing patterns and responding to them makes practice possible, although numerous examples in Jerome Groopman’s book illustrate the dangers of these thought processes.

Lots of doctors proclaim that they do not practice “cookbook medicine.” In other words, they treat each patient individually rather than relying on rules, flowcharts, and other “cookbooks.” Of course, they all do rely on rules to some extent- the important thing is to realize when the pattern and response to treatment vary in some important way that will influence the patient’s outcome.

As I noted at the end of my earlier post, my rule seems to be serving me well. I spent far more time considering why I formulated it than I took to create it.

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