State of the Science: About one-third of all vaginal births in the United States include an episiotomy. Proponents believe that uncontrolled tearing of the vagina is both harder to repair than a neat surgical incision and poses a greater risk of complications like urinary incontinence or poor sexual function.
Prognosis: Now it turns out that as widely held and reasonable-seeming as the beliefs about routine episiotomy are, they are nonetheless wrong. Katherine Hartmann and her colleagues critically reviewed and aggregated the results of many studies and found that the practice has no benefit and in fact may contribute to poorer outcomes for mothers. The researchers urge that routine episiotomy is unnecessary and say further studies should define the circumstances in which it is valuable (when fetal distress requires a very fast delivery, for example).
Lesson: To a much greater extent than most people realize, medical practice is determined by adherence to tradition and by reasoning from plausibly related research or personal clinical experience. This probably sounds terrible, but it shouldn't. It's the product of a normal style of human thinking—the one that directs us to infer that if one event closely follows another they are probably related in a cause-and-effect way (which is sometimes right but often wrong). In addition, most questions in medicine about cause and treatment have never been asked in a serious, rigorous way. As a result, every doctor has at some time blindly, desperately, and irrationally ordered some last-ditch treatment, because we have a patient who needs help and we cannot think what else to do. And if our treatment "works"—that is, the patient improves—few of us have the intellectual rigor to resist associating it with the patient's improvement.
Fortunately, more and more long-held beliefs and traditional practices are being skeptically examined. I'm a pediatrician, and I don't do episiotomies, but as I read Hartmann's paper I was stimulated to think of the many things I do, all blessed by tradition and reason, that are nonetheless probably incorrect and maybe harmful. I hope it will not be too painful to shake off fusty beliefs that I am irrationally sure of and replace them as new ideas, supported by evidence, are introduced.
Age-old Wisdom: Newer treatments aren't necessarily better.
Contrarian thought: One of my greatest irritations about modern medicine is the degree to which it devalues old knowledge. My young colleagues and students, as bright and thoughtful as they are, don't bother to look at papers that are more than five years old—it's as if that's Neanderthal work.
So, I was pleased to open one of my favorite journals this week, the Lancet, to find a letter by two British surgeons, Peter Bewes and Maurice King. Their note commented on a paper published earlier this year that used the best methods of evidence-based medicine to compare two up-to-date ways of managing leg fractures in children. Bewes and King pointed out that the paper's authors neglected to include an older method that is low-tech, more conservative, and may offer substantial advantages over the newer methods. The old method has a better track record than the modern ones of keeping the bones in a good position as they heal and of preventing the infections that can occur when healing bones are pinned in place. They worry that with the publication of this new study, the older method may be rejected out of hand. Bravo to these authors for reminding us not to neglect ideas just because they've been around for a while!
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