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I tip my hat to likes of Orac, Sandy, and Robert Centor.  They don’t shy away from a debate or a contraversial topic; in fact, they seem to greet it with open arms.  This takes a frame of mind that I find difficult to hold for very long – one that thoroughly examines the details of issues and comes up with a defendable position.  I think this type of debate and scrutiny of issues is very important in that it attacks dogma and challenges assumptions, forcing us to make sure evidence is good for the things we are doing.  But if I spend much time doing this, I find myself reaching for the Tylenol.

In a recent post in his blog, Centor challenges the dogma of getting the hemoglobin A1c down below 7.0, questioning whether the benefit of getting diabetics to that level is worth the risk of using medications like the thioglitazones (of which Avandia is presently the most famous). 

The truth is, these kind of questions make me feel quite uncomfortable, given that I am a practicing physician who has used this class of drug to get diabetics to that very goal.  Challenges like this are not just of academic interest to me, they would drastically change the way I practice medicine if my practices (the accepted medical practices) were found to be false.

The problem is that I am a doctor, not a scientist.  I practice applied science, not science.  I do realize that this statement is a generalization, and some of what I do is, in fact, scientific, but the majority of what I do is based on other people’s experiments, analysis, and opinion.  I don’t have time to scrutinize all of the literature as to the benefit of lowering the A1c, nor do I have time to see all sides to an argument.  Just like my patients, I get confused as to how to interpret two intelligent opposing opinion.  In fact, such arguments quickly give me a headache.

The problem is that I must decide, where others don’t have to.  An academician can argue all they want and not come to a conclusion, but I must decide if I am going to bring my diabetics to goal or not.  I must form an opinion because they are coming to see me in the office for that very opinion.  So instead of looking over all the evidence myself and forming an opinion, I do the following:

• I look to "expert" panels as to recommendations on what should be done.  For instance, I look on UpToDate.com and ACP medicine to see the reasoning of A1c lowering.
• I rely on my past experience.  For example, the child with the rash looks much like one I have seen before. 
• I use statistics.  Doctors have a billion statistics in their head.  I use them in my choice of medicine and my decision to order tests.  When someone comes to me with chest pressure that radiates down the arm, I ask myself: ‘what is the likelihood that this is heart disease?"  If I think a story is very consistent with true cardiac angina, I may recommend a patient get a cardiac cath instead of a stress test.  A lower risk person would get a stress test, and a very low risk person would be reassured and sent home – all with the same story.
• I avoid worst-case scenarios.  This is particularly true in pediatrics, where we do a spinal tap on young children simply for a fever.  Yes, you know it is unlikely to be meningitis, but the simple fact that it could be makes you do a very invasive test.
• I try to adhere to best practices.  Best Practices are the generally accepted medical care at the present time.  If you deviate significantly from best practices, you had better have a reasonable explanation for why you did not do the "normal" thing, or you will be liable for consequences – deserved or not. 

So these challenges to my dogma really put me in a conundrum.  I have to choose what to do.  Do I really want to hear the possibility that what I am doing is wrong?  Do I really want to know that Statin drugs may not be helpful, that obesity may not be as harmful as some say, that good diabetes control may not be as important as I am told? 

It certainly is worth debating.

But it really gives me a headache.  I am a doctor, not a scientist.