Accepted Practice ≠ Best Practice

 Vrinda Modi

Accepted Practice ≠ Best Practice

Picture this: You’ve just been wheeled into the ER, neck braced by a cervical collar, surrounded by doctors and nurses. You trust them, and why wouldn’t you? After all, they are the experts, the ones who hold your life in their hands. But what if I told you that some of those “expert” decisions were based on decades-old guidelines, not solid evidence? And what if I told you that many of those doctors skimmed through the very research that shaped the standard of care you’re receiving right now? The reality is that maintaining true expertise in medicine is an ongoing challenge, and nearly 1 million PubMed articles are published each year. To say that the scientific and medical community is inundated with information—much of it questionable—is almost an outdated statement.

John Ioannidis, a physician-scientist at Stanford, highlights in his study a key problem in the medical misinformation mess: many healthcare professionals and clinical leaders fail to critically assess the accuracy and bias of medical research. He points out that many internists rely on reading just the abstract of a research study and assume that the journal itself guarantees reliability. However, nearly half of the abstracts from randomized controlled trials exhibit biased reporting, which can lead to flawed and sometimes contradictory clinical practices. These practices become embedded in our healthcare system, contributing to suboptimal outcomes and reinforcing the need for more rigorous evaluation of medical research.

Take the cervical collar (C-collar), used in EMS for spinal immobilization. As an EMT, I was taught to place a C-collar on any patient with a traumatic injury and signs of spinal injury to limit head and neck movement. (Figure 1). Failing to do so can even draw judgment from ER doctors and nurses.

Figure 1. Average reaction from a patient on a C-collar.

C-collar use became an EMS guideline in the 1970s, endorsed by the American Academy of Orthopedic Surgeons. However, Milland, a researcher at the University of Tennessee, notes that this standard was based more on “consensus than evidence”. In fact, new research suggests that cervical stabilization can even lead to higher rates of morbidity and mortality because of delays in resuscitation, increased intracranial pressure, and other injuries, as reported by Muzyka and colleagues at the Dell Medical School at UT Austin.

So, how do we know if the benefits truly outweigh the risks? It depends on who you ask. A 2021 study by Thompson and collaborators found that trauma hospitals were more accepting of EMS not using C-collars, while non-specialist hospitals less exposed to traumatic injuries were less so. This is true for a lot of medicine. As Irwing, Emeritus Professor of Epidemiology at Syndey Medical School pointed out in his 2008 book, Boston and New Haven have populations with similar healthcare demands, both of which are served by practitioners linked to world-class medical centers. However, New Haven residents are about twice as likely to receive heart bypass surgery, while Boston patients are more often treated with other methods. Conversely, hip and knee replacements are more common in Boston, whereas New Haven doctors typically recommend non-surgical treatments. And examples like these just further highlight the discrepancies between clinical research, doctors, and actual practice. The worst part is that all of this compounds into poorer patient outcomes since we do not truly understand what “best practice” is. 

Figure 2. The Catch-22, in a nutshell.

Ioannidis emphasizes that medical training does not do a good job of incentivizing or encouraging analysis of evidence-based medicine. A huge foundation of medical education is the consensus of experts. But we know expert views can be wrong, contradict each other, or straight up be opinions. This further complicates medical decision-making, especially when doctors are taking into consideration the million other factors that affect your health. Not only that, but healthcare outcomes are uncertain since different practices affect people differently, which is exactly why much of clinical research is probabilistic evidence. So, a good amount of our trust in the healthcare system is the assumption that physicians know what they’re doing. Irwig aptly quotes physician, and healthcare analyst David Eddy in his book: “Somehow, the assumption goes, physicians are able to assimilate all they have learned from their medical education, their training, research, their personal experiences, and conversations with their colleagues, as well as all the information about their patients – their signs, symptoms, hopes, and fears – to determine the right thing to do.”

I do fear highlighting this issue will only further exacerbate the public distrust of healthcare. However, it is crucial to address these challenges to improve medical practices and patient outcomes. As someone aspiring to become a physician, I deeply admire those who engage rigorously with research since true expertise requires continuous learning, not just the facade of competence. And let’s be honest—anyone who reads past the abstract? They deserve a medal.


References

  1. Ioannidis, J. P. A., Stuart, M. E., Brownlee, S., & Strite, S. A. (2017). How to survive the medical misinformation mess. European journal of clinical investigation, 47(11), 795–802. https://doi.org/10.1111/eci.12834

  2. Milland K, Al-Dhahir MA. (2023). EMS Long Spine Board Immobilization. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. https://www.ncbi.nlm.nih.gov/books/NBK567763/

  3. Muzyka, L., Bradford, J. M., Teixeira, P. G., DuBose, J., Cardenas, T. C. P., Bach, M., Ali, S., Robert, M., & Brown, C. V. R. (2024). Trends in prehospital cervical collar utilization in trauma patients: Closer, but not there yet. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine, 31(1), 36–41. https://doi.org/10.1111/acem.14822

  4. Thompson, L., Shaw, G., Bates, C., Hawkins, C., McClelland, G., & McMeekin, P. (2021). To collar or not to collar. Views of pre-hospital emergency care providers on immobilisation without cervical collars: a focus group study. British paramedic journal, 6(1), 38–45. https://doi.org/10.29045/14784726.2021.6.6.1.38

  5. Irwig L, Irwig J, Trevena L, et al. (2008). Don’t always rely on the experts. Smart Health Choices: Making Sense of Health Advice. London: Hammersmith Press. Chapter 4. https://www.ncbi.nlm.nih.gov/books/NBK63655/

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