Blog | Thursday, June 14, 2018

The value of controversy in medicine as it relates to sepsis


Everywhere I look in medicine today I see controversy. We see competing guidelines. We see subspecialty organizations write indignant screeds about another organizations guidelines.

One of the most popular Grand Rounds styles involves debates. The audience generally rates debates very highly.

As physicians we approach medicine cerebrally. Controversy should make us think. We actually like thinking.

Perhaps the largest current controversy involves the sepsis bundle. While this controversy is attracting much heat, we have many other important controversies.

Why do these controversies develop? With apologies to true believers, we must return to my favorite Nietzsche quote, ”There are no facts, only interpretations.”

We in medicine value evidence. We assume that we can resolve controversy with data. But almost all interventions carry harms and benefits. How much harm should we tolerate to achieve how much benefit? Until we understand that problem, we cannot really understand the reason for controversy. Confirmation bias also complicates this problem. In confirmation bias (to which we all fall prey), we highly value any evidence that supports our beliefs and discount evidence that would argue against our beliefs.

In the sepsis guideline and bundle controversy, some experts want to assure that we miss no patients with sepsis. They highly value any intervention that might decrease sepsis deaths or severe morbidity. They discount inappropriate antibiotics for “false positives”. In order to increase sensitivity, you must sacrifice specificity.

Our screens for sepsis have mediocre sensitivity and specificity. As quoted in Annals of Internal Medicine, “qSOFA had poor sensitivity and moderate specificity for short-term mortality. The SIRS criteria had sensitivity superior to that of qSOFA, supporting their use for screening of patients and as a prompt for treatment initiation.”

Many, include the Infectious Diseases Society of America (IDSA), worry about overuse of antibiotics. They argue that patients with possible sepsis deserve a careful clinical assessment. As quoted in the ”Infectious Diseases Society of America (IDSA) POSITION STATEMENT: Why IDSA Did Not Endorse the Surviving Sepsis Campaign Guidelines,” “Our societies had different perspectives, however, regarding the interpretation of the major studies that informed the guidelines' recommendations, thus leading us to different conclusions and different perspectives on the recommendations. IDSA consequently elected not to endorse the guidelines. IDSA nonetheless hopes to be able to continue collaborating with the Surviving Sepsis Campaign and the Society of Critical Care Medicine to resolve our differences and to develop further strategies together to prevent sepsis and septic shock as well as reduce death and disability from these conditions both nationally and globally.”

It becomes even more complex when we consider the proposed CMS sepsis bundle. This article from Annals of Internal Medicine, “SEP-1 Hemodynamic Interventions,”addresses this component when it says, “Conclusion: No high- or moderate-level evidence shows that SEP-1 or its hemodynamic interventions improve survival in adults with sepsis.”

We must hope that this controversy will lead to gathering more information to resolve the controversies and improve care. Science demands controversy. Medicine demands that we view everything critically. My opinions on the controversy are not as important as exposing the controversy.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.