One of the most interesting things about action research is when you observe yourself implementing your maneuver: and see when you break rules. Breaking rules in action research is teaching yourself about you, and learning how your intervention doesn’t quite fit reality.
I’m implementing US lipid guidelines. They suggest maximum dose of crestor is 20 mg, as only one study published has doses above that. Lipitor top dose 40-80 mg. Fuzzy. So I tend to pick crestor. They mention the other dinosaurs, and recommend trying them if there are reactions to our current standard choices. They suggest in those situations the top tolerable dose that fits the clinical scenario. Ezetrol is gone, as are the omega 3’s, and other “add-ons”, whatever they are, co enzyme Q10 and what have you.
I love these guidelines, and realize that my emotional reaction to them is a problem. Not very scientific, is it, to love a guideline. But this approach sort of fits my psyche, my belief about an ideal approach to medicine. Treat the patient, not the lab data. It’s one of my mantras. I’ve always had as one of my questions to my students, “What if there was no lab…What would you say this was? Top diagnosis. How would you treat it?” Usually this in the face of an overweight, tired, sad, patient wearing a sweater, with “normal” thyroid function tests. But that question is useful in any scenario. We’ve come to ignore clinical findings, or to down play them in light of lab data. We tend to rely on lab tests, and think of what ones we want, even prior to doing vitals….
Which reminds me of a story, which I have to share, an aside, a short little side trip worth a sight see. While doing my American Boards years ago, I guess it was actually part 3 USMLE, I was…how can you say…NERVOUS. The awful thought occurred to me, what if I failed? Imagine failing the USMLE 3, the exam that says whether or not you’re fit for clinical practice, after you had been practising for 10 years?? Nervous.
Back then it was all on paper. One humungous question, replete with clinical scenario, lab work, imaging, pathology slides, you name it, had as its only question at the bottom: what would you do next? a) order a PET scan b) order a MRI c) check the rhubarb level, or d) do the vitals. Well, DUH.
At coffee break, I walked around, and overheard heated debate about whether it was the PET scan, or the MRI. Needless to say I wasn’t nervous anymore.
Anyway, interesting little side trip!
So, back to the main path, I have been trying to fairly rigidly apply these guidelines. The reality bites are when things jar with that wonderful mental landscape you’re trying to develop. You know, the one where everything just fits wonderfully, and people are on the right dose of med for their particular scenario.
And then you get the post MI patient, not on a statin, with an LDL of less than 2. Gulp. I did it. I put them on crestor, and I did it at 20. And it wasn’t easy. Why? Because of a clash of belief systems. I love the US guidelines, but I’ve been practising aiming for goals for years. And, I prefer not to use a drug, when exercise and diet are the cornerstone of more than just lipid therapy. Medicine! And perhaps healthy life, period.
I discovered that viscerally, I was using these lipid guidelines to get people off pills! That was usually the scenario. Patient after patient, doses were dropping, and a day usually didn’t go by that one or two people actually went off their statin. Should a scientist enjoy discontinuing a statin? That should be a logical, cold analytical decision.
I clearly enjoyed it. That says something, about me.
Realizing that enabled me to put that post MI patient on crestor 20. I honestly don’t know if I would have done that without the formality of analyzing my approach using an action research scenario. Breaking rules in action research is actually difficult. You’ve decided on an approach, a strategy, you have a road map.
Do you have any morbidly obese diabetics with insulin doses in the hundreds of units? With TGs over the top, several times the usual range? I have a couple. Cholesterol also mind boggling, on crestor 40. And ezetrol. And, frankly, an awful diet, and sedentary.
I broke the rules there. I just couldn’t do it. Breaking rules in action research is sometimes helping your patient. I hope. I chose a drug regimen not fitting the protocol. And lectured, cajoled, tried to motivate, and almost shook the chap by the lapels to try to get him to walk. And stop the cookies.
Possibly pointless, but we have to try, right? Are you one of my colleagues that have given up?
Look at a short video. It might help you with counseling your patients to start walking. It’s on You Tube! I’ve even played this for patients who didn’t own a computer, right in the exam room. 23 ½ hours exercise, by Dr Mike Evans. It’s a cartoon, about 8 minutes long, that’s actually gotten people to move, that have never before heard my advice. That’s worthy of action research right there! Here’s a link to his YouTube page, where there is this and a few other good videos:
What else? If you have a patient that will read, which is getting harder to find, try Katz’s
Disease Proof. I’ll put a link below, there’s a kindle edition for $14. He’s got some YouTube videos as well.
And no, I’m not getting some kind of an affiliate fee for recommending either of them.