I read with interest Dr. Faust’s column of June 2013 titled “EBM and the ‘Five Stages of Grief.’” I myself am a proponent/practitioner of EBM and consume with enthusiasm attempts by our colleagues to degrade “false dogmas” in medicine. However as a young attending, I have learned a few things about EBM “zealotry” that may be useful to Dr. Faust and other residents embarking on their careers in emergency medicine. I will respond to Dr. Faust’s comments on the five stages with some practical information from my first year of solo clinical practice.

Denial, or, “I was taught that it works!” – Hearing from another doctor that one has been practicing in a way that has not been shown to be beneficial for patients is not a fun piece of information to assimilate. At the bare minimum, when presented with information like this, my inclination is to withhold judgment until I have a chance to review the literature for myself.

Anger, or, “How can you have the audacity to say that the AHA is stupid?” – If one wishes to mine specialty society guidelines for practice recommendations lacking solid evidence one is entering what our friends in the military call a “target rich environment.” It is, I suspect, far easier to criticize organizations like the AHA than it is to create clinical guidelines for them which will be read globally and implemented by physicians of varying levels of expertise and interest. As such guidelines tend to lag behind the literature a bit and often represent more conservative practice patterns than those of the most cutting edge physicians.

Bargaining, or “This treatment can’t be studied!” – It is very difficult from a cognitive sense to supplant your own practice experience with data from a paper. For example having read all the literature on central venous pressure and its non-existent relationship to intravascular volume and pre-load I will tell you that I think it is a useful number when it is –2 or 20. I have no evidence for that statement other than my own practice.

Depression, or “Was everything I taught all for nothing? Are we no better than the charlatans of yore? Were my teachers lying? Are the boards filled with drivel? Are all of my colleagues a bunch of suckers? Am I one?” – In order: no, no, no, no, partially, possibly.

Acceptance – If you have made it this far with in your argument with your less zealous colleague there are probably at least three new patients waiting to be seen. And they all want Zpacks.

–Matthew Pirotte, M.D.