Like Jess, I have also just begun my cardiopulmonary placement at a major teaching hospital and have been faced with my first clinical dilemma.
I have noticed in many of the patient notes that the consultants have recommended the use of incentive spirometry (IS) post surgery to prevent postoperative pulmonary complications (PPCs). In lecture, we’ve learned that there has been little evidence to prove that IS has clinical benefit over other physiotherapy techniques in preventing PPCs. Having come home this evening and done a search on the Cochrane Collaboration, and explored a variety of search engines, I have not been able to find firm evidence of IS preventing post-op pulmonary complications.
Our research unit tells us that expert opinion has minimal levels of evidence, and that randomized controlled trials are much higher on the hierarchy of the levels of evidence. My question is then, why do doctors continue to prescribe the use of IS post-op if there is little evidence supporting its use?
IS disposable units cost more than $100 each, which can become quite expensive for the hospital if it is being recommended for most post-op cardiothoracic and abdominal surgery patients. How can this cost be justified if the evidence supporting the use of IS is so conflicting? I spoke with my clinical supervisor about what she does in these situations. She wasn’t able to give me a definitive answer, as most of the time it depends on how firmly the consultant believes IS is necessary. Often, she is able to substitute IS with other physiotherapy breathing techniques and exercises.
This conversation with her made me realize how difficult it must be to provide a treatment even though current evidence states that benefits from it have yet to be proven, however you are part of a hierarchy that demands you do it anyway.
I feel I am becoming more aware now of the struggles that we will be faced with upon graduation when we begin working. Over the remaining 12 weeks of clinical placements, one of my goals will be to develop the skills that are necessary for dealing with conflicting evidence and differing points of view. My question to you as students, is how have you dealt with scenarios such as this and what are your thoughts on how to deal with them?
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2 comments:
Usually it’s difficult to change the ways or minds of those who are arrogant or just stuck in their ways. For this reason I would target younger more impressionable doctors who are usually more willing to take on board logical and scientifically proven ideas. In the end the younger doctors may have a better chance of changing the minds of older doctors. It’s kind of like those insect killer commercials where you poison one insect which then goes back to the nest and spreads it to the colony.
Hi Meghan, this is quite an important issue that you have raised adn I think it is worth asking more widely of experienced clinicans what they do. I used to just do what the consultant requested but (having had more assertive behaviour modelled to me by colleagues) now I see these situations as opportunities for us to advance the profession. I have heard Senior colleagues tell me that they go to the consultant(s) and speak to them and give them a brief verbal summary of the evidence, offer to put it in writing and advise the consutant(s) of what the physio's plan to do and what additional input they will do if any complication develops. As a graduate this could make a nice QA project. I personally am glad that the consultants and registrars show an interest in what can be done to prevent post op respiratory complications and as I said- see this as an opportunity to demonstrate what we know and how we can communicate.
All the best
Stephanie
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