Abstract
I
Some of us provide care for a population, such as all the infants born at a community-based maternity center; others work in tertiary care hospitals where the sickest and most complicated families come for care. Some of us provide primary care, and others see referrals of dyads who have undergone multiple evaluations and treatments and are seeking a third or fourth opinion.
This context matters, because the mixture of patients who we see affects the patterns we perceive, and these patterns shape our clinical practice. In epidemiology, this is called “Collider Bias,” and it emerges when the factors that select individuals into a population create artificial associations. Griffith et al. 1 illustrate this with an example: consider a group of students who attend a prestigious university. To be admitted, a student needs either academic or athletic ability. These paths to admission create an association, in which better athletes have lower grades, even though in the real world, athletic and academic skills are not related.
What might this have to do with breastfeeding medicine? We each inhabit our own clinical ecosystem. A general practitioner sees a different population than a pediatric immunologist, and an emergency room physician sees a different population than an otolaryngologist. Over years of experience in our clinical realms, we hone our diagnostic intuition about what “makes sense” and what does not.
When physicians from different clinical realms come together, it can be a bit like the blind men and the elephant. In this fable, a group of blind men approach an elephant, each touching a different part of the animal. The blind men begin to argue, with one insisting that he is feeling a snake (the trunk), another that he is feeling a pillar (a leg), and another a broom (the tail). As Popple writes, “Our individual views of the universe may be different from one another's because we each encounter only one small part of what is there.” 2
I first began to appreciate the peculiarities of my own clinical world when I was working with a team of pediatricians on guidelines for treating thrush in breastfeeding infants. I was hoping to get support for treating infants of mothers with breast pain with oral fluconazole. The pediatrician I met with was perplexed. He told me he often sees babies with oral thrush in routine well-child visits, and if feeding is going well, it is typically self-limited, and no treatment is needed. I was indignant, and said, “All the babies I see with thrush have feeding problems!” As I spoke, it occurred to me that every baby I see in my breastfeeding medicine clinic is there for a feeding problem—vastly limiting the implications of my clinical experience to the broader world.
As a member of the ABM board for most of the past decade, I have seen disparate perspectives conflict as we craft protocols for clinical practice. Authors bring lived experience in different clinical settings to guideline development. We also bring the context of health care systems on six continents, with vast differences in practice patterns, access to care, medication formularies, antibiotic resistance, and expectations around shared decision making for patients and providers. The diverse experiences of ABM members are a core strength of our organization, as well as a central challenge, because there cannot be collaboration without conflict.
Through hours of discussion, writing, and rewriting, the members of the protocol committee work to integrate differing perspectives and share guidance that is applicable to clinical contexts around the world. It is hard work, and it requires each team member to consider evidence and practice from contexts outside of their own clinical experience in the services of our shared commitment to protect, promote, and support breastfeeding families.
Above all, this is humbling work. It reminds me that as physicians, we are constantly honing our clinical intuition, always remembering that “we each encounter only one small part of what is there.” The strength of ABM is that when we bring our small parts together, we can see the entire elephant, enabling clinicians around the world to improve health across generations.