Evidence instead of Evidence

The Washington Port is reporting concerns about the use of magnesium sulfate in preventing early labor. This fascinates me for a few reasons. I was briefly monitored for possible "early labor" at 34 weeks gestation (my baby would have been born 7 weeks early). I thankfully avoided magnesium, (but got a shot of terbutaline, which is a story for a different day). At it happened, I didn't go into labor early -- in fact not until 10 past my "due date" (41 weeks 3 days, which I'm now learning is exactly average). But I ended up finding magnesium sulfate anyway, when I was diagnosed with mild pre-eclampsia.

The Post article doesn't challenge magnesium’s use to prevent seizures. But no matter why it's used, the drug's side effects still "range from highly unpleasant to lethal." I guess this doesn’t surprise me, even though no one told me this before they started pumping the Epsom Salts into my veins. I’m sure I had signed some intake paperwork that waived my right to be informed of drug dangers when something critical like a seizure (maybe, possibly, until we get your bloodwork back) might be on the line.

I can vouch that an IV of magnesium, even without a severe complication like "life-threatening pulmonary edema, in which the lungs fill with fluid," is no walk in the park. Reading the article brought it all back to me: nausea, blurred vision, headache, profound lethargy, [and] burning sensation[s]. They don't mention the mad craving for ice cream (especially acute after going without food and water for 20 hours), which can be tolerated only by playing slightly delirious games where you demand that everyone in the room help you name all 31 Flavors of Baskin Robbins Ice cream (I still can’t believe we couldn’t do it – but then we were all pretty tired).

The Post article is noteworthy for another reason: it quotes obstetricians blatantly admitting what I'm always suspcicious about -- that they are more concerned with malpractice liability than patient safety. As Dr. Michael Gallagher, a specialist in maternal-fetal medicine, or high-risk pregnancy, puts it:

. . . jettisoning a long-standing practice [magnesium for preterm labor] in obstetrics involves factors other than evidence, some doctors say. They note that the standard of care -- a benchmark of evidence in malpractice cases -- as well as patients' wishes and the desire to prevent a bad outcome such as premature birth -- all contribute to continued use of the drug . . . "Suppose we don't use it [to stop pre-term labor] and a patient delivers [early and the baby dies]," Gallagher said, noting that might violate the prevailing standard among OB-GYNs. "You find yourself in lonely places."

Oh, those lonely places. So even when the hard, scientific evidence casts doubt on a drug’s safety and effectiveness, the "standard of care" still won't change because each doctor is afraid to stand out from the crowd. They're more concerned with the potential "evidence" that might be brought against them in a malpractice lawsuit -- the testimony of trial experts who tell a jury what "all the other doctors do." They are safe from liability as long as they act consistently with each other -- as long as they all do the same thing -- regardless of whether it protects patients.

It makes me wonder what Dr. Gallagher would do if all the other obstetricians jumped off the Brooklyn Bridge. Would he follow them? (Maybe if they threatened to raise his insurance premiums?) Or is this beside the point – since it’s the mothers and children, in this metaphor, being asked to line up and jump.

On the other hand, maybe all the doctors are desperate for some sensible freedom from the viscious cycle of standards and liability. It reminds me of Cass Sunstein's hockey helmet theory -- hockey players always knew they'd be safer with helmets, and wouldn't have minded wearing them. But no one wanted to be the first person to be different, so they didn't wear helmets until it became mandatory. According to Sunstein, there's no bright line between what's "rationa" (ie, evidence based medicine) and the "social norms" (how you'll be judged -- literally -- compared to all the other obstectricians). In fact, peer pressure can influence our beliefs until the "norms" become intertwined with our deepest levels of thought. It's easy to imagine this happening in medical education, where new doctors learn not just from research but from the practice, anecdotes and experience of other doctors -- even when this becomes distorted (perhaps through single a dramatic example, like a fetal death) from what what evidence-based medicine would tell us.

Things become even more distorted when we bring "patients’ wishes" into the discussion. Patients know nothing about magnesium – or any medical intervention – until their doctors tell them. And patients facing preterm labor surely pressure their providers to do whatever they can to help. But perhaps this is just another symptom of our inflated faith in what medical technology should do for us. Who’s to blame for that?

As far as the Post article goes, I did find myself touched to read that another OB/Gyn, Gary Cunningham of University of Texas Southwestern Medical Center, had the empathy to once take magnesium sulfate himself to see what it was like. "It was scary," he said. "You feel like you're burning up."

Yep, scary. A burning arm where the IV enters. Double vision, flu-like symptoms, sweating, chills and vomiting. Enough to scare a healthy, symptomless man in controlled research conditions – even scarier for a woman in labor who is fearing a premature birth. And scariest of all -- it probably doesn't help her.

Lonely places.