Editor`s Opinion: The Chicken, The Egg, and The Box

    I know — “thinking outside the box” is a well-worn phrase. Most of us barely seem to have time to think “straight” let alone “outside the box.” Plus, the well-established principles of science — ie, we build upon previously reported findings — along with our natural tendency to remember and refer to recent publications and those that confirm our own previously held beliefs allow us to take and fit what we read and discuss neatly inside the box.

    Life inside the box is comfortable and secure. However, as Michael Miller and Chris Lowery remind us in this issue of OWM, advancements may be stymied when we accept dogma as fact and fail to look outside the box. Similarly, Karen Zulkowski and Patricia Coon, via the diabetes study findings reported this month, remind us that standard study methods, using patient records and the provider’s perspective, provide only a narrow window into our understanding of how to improve outcomes.

    With regard to dogma and boxes, Kirsten Berg and Heidi Seidler note, en passant, that the practice of cleaning and reusing colostomy pouches is deemed unhygienic in Germany (and most other European countries) but generally considered standard practice in the US. In a society that is not exactly averse to using disposables, why was (or is) cleaning and reusing disposable ostomy pouches acceptable? The usual, standard answer to this question is “reimbursement guidelines.” What were the recommendations made to the Medicare panel and who made them? Did persons who actually have to clean their pouches testify or were decisions based on existing practices adopted by necessity when only reusable pouches were available? What came first — reimbursement guidelines or actual practice? If the latter, what was the evidence for this recommendation? Would that evidence still hold true? As another example, current thinking holds that chronic wound healing differs from acute wound healing. The most commonly cited explanation for this theory is that the wound fluid of chronic wounds and acute wounds differ considerably. However, is the presence of less-than-optimal wound fluid the result of an underlying pathology and a wound that is (unsuccessfully) trying to heal or is it an important cause of observed wound healing differences? What came first: delayed healing or changes in wound fluid? If the former, the primary goal of care should be to reduce the adverse effects of the underlying pathology. If the latter, research should focus on manipulating wound fluid.

    Thinking outside the box and pondering whether the chicken or the egg came first are crucial in both research and practice. If we want to provide optimal care, we must always have a healthy dose of suspicion and expect the unexpected. You may not practice in an area indigenous to brown recluse spiders but if you see a patient with symptoms such as those described by Judy Wilson, Clyde O. Hagood, and Irvine Prather, taking a complete history, including recent travel, can make the difference between life and death. And speaking of life, death, and diagnosing unusual skin lesions, physicians at a Miami hospital now believe that one of the highjackers who piloted the planes on September 11, 2001, was hospitalized with cutaneous anthrax in June 2001.¹ Would world history have changed if the black lesion on his leg been had been correctly diagnosed that summer?

    Thinking outside the box may be a well-worn phrase and pondering “what came first” questions may seem like a time-consuming luxury. Utilizing these approaches may be uncomfortable at times but never boring… contentious perhaps, but always progressive. Tiring? You bet. But isn’t that why we do what we do instead of counting eggs and chickens?

1. Cole LA. The Anthrax Letters. Washington, DC: Joseph Henry Press;2003.