Nutrition Support Blog: Controversy is Essential to Progress
November 21, 2011
We just had our ASPEN state chapter annual meeting (VASPEN) last week and it was a great meeting with wonderful speakers. I find that the state conferences and clinical nutrition week are a great way to stimulate ideas and recharge your enthusiasm for implementing changes.
One of the phenomena that will sometimes occur at these conferences is that two distinguished and learned speakers will offer viewpoints that are diametrically opposed, such as XYZ amino acid is the greatest thing since sliced bread, but then a later speaker may claim that there is no good data to support any benefit from the same amino acid. Understandably, many clinicians can feel confused or frustrated by the fact that national or internationally acclaimed speakers make statements in opposition to each other. Clinicians have frequently asked us “who is right?” and with our extensive experience and detailed review of the literature, we are able to confidently tell them “EXACTLY.” (Who IS right?)
While our answer may seem a bit glib, the truth is that at times, the fact that experts disagree is the most important thing that you may learn at a conference. Understanding the true value of these uncertainties, not just acknowledging that people disagree, but a full appreciation for the nuances of what we don’t or can’t know because of the limitations of the data (or different interpretations of the data) is central to the transition from intermediate to expert practice.
In school, and for less experienced practitioners, it is necessary to first teach “facts,” to memorize the basics in an organized manner before you begin to encourage clinicians to question the status quo. Truisms such as: vitamin C deficiency causes scurvy, providing copious amounts of carbohydrate without thiamine is a Bad thing, avoid commenting on the benefits of checking gastric residuals around Carol Parrish, etc. However, in the medical arena, once such basic notions are established, it is absolutely essential to learn when and how to question current practice. If no one ever challenged expert practice or opinion, bloodletting would still be state of the art, and the most advanced nutrition support would be nutrititive enemas of egg, whiskey and water like those give to President McKinley after he was shot in 1901.
Of course, the process of questioning and disagreement among experts is not always completely comfortable and stress-free. Suggesting that conventional practice or one interpretation of the data is suspect can incite a sharp response, especially if there is an implication that past opinion or practice can cause harm. In fact, it appears at times that there is an inverse relationship between the robustness of the evidence and how heated and emotional the discussion is. However, I have observed that often the most experienced and wisest clinicians are the most tolerant to challenge. Many experts relish a thoughtful and diplomatic contest of ideas because they recognize the benefits that come from these exchanges. Although it does not occur nearly as often as it should, in fields of science (unlike politics or religion), experts can discuss matters, look at new data (or the old data in more detail) and actually change their position or practice. Naturally, when the challenges are more passionate than polite, the exchanges that follow may seem less than collegial. However, when passionate debates between experts ignite, I have found that the resulting discussions or letters produce a wealth of insights and knowledge far beyond what is normally seen in courteous editorials. (For just one such example, look up the following on Pubmed and read the editorial and the letters in response: Marik PE, Pinsky MR. Death by total parenteral nutrition. Intensive Care Med 2003;29:867-869).
While we would all like to go to conferences and come home with concrete answers to our questions, this is frequently not possible in many cases due to the limitations of current knowledge. I would encourage everyone to pay the most attention when experts disagree, especially if some say the data is unclear, and then another posits a definite answer to the problem. Once you return home, use your superpower of attention to detail, inherent in all nutrition support practitioners, and critically evaluate their references to develop your own challenge to conventional wisdom. Then you really will have learned something.
“The daily round of a busy practitioner tends to develop an egoism of a most intense kind, to which there is no antidote....
.... The medical society is the best corrective, and a man misses a good part of his education who does not get knocked about a bit by his colleagues in discussions and criticisms.” ~ William Osler, 1897
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