Narrated and Abridged: There is (No) Evidence for That: Epistemic Problems in Critical Care Medicine

Below is the narrated video of my powerpoint presentation on Epistemic Problems in Critical Care Medicine, which provides a framework for understanding why we have both false positives and false negatives in clinical trials in critical care medicine and why we should be circumspect about our "evidence base" and our "knowledge".  This is not trivial stuff, and is worth the 35 minutes required to watch the narration of the slideshow.  It is a provocative presentation which gives compelling reasons to challenge our "evidence base" in critical care and medicine in general, in ways that are not widely recognized but perhaps should be, with several suggestions about assumptions that need to be challenged and revised to make our models of reality more reliable.  Please contact me if you would like me to give an iteration of this presentation at your institution.

Therapeutic Agnosticism: Stochastic Dominance of the Null Hypothesis

Here are some more thoughts on the epistemology of medical science and practice that were stimulated by reading three articles this week relating to monitoring interventions:  monitoring respiratory muscle function in the ICU (AJRCCM, January 1, 2013); monitoring intracranial pressure in traumatic brain injury (NEJM, December 27, 2013); and monitoring of gastric residual volume in the ICU (JAMA, January 16th, 2013).

In my last post about transfusion thresholds, I mused that overconfidence in their understanding of complex pathophysiological phenomena (did I say arrogance?) leads investigators and practitioners to overestimate their ability to discern the value and efficacy of a therapy in medicine.  Take, for instance, the vascular biologist studying pulmonary hypertension who, rounding in the ICU, elects to give sildenafil to a patient with acute right heart failure, and who proffers a plethora of complex physiological explanations for this selection.  Is there really any way for anyone to know the effects of sildenafil in this scenario?