I recently ran across this clip discussing how much weight we should give to research and academic elites vs following our common sense.
In healthcare, we have an obsession with the idea of evidence-based medicine. Don't get me wrong, I am very much in favor of making sure that the medical care that we provide is based on the best available evidence. That is, after all, what has propelled us into the modern era of medicine.
If it were not for a sense of discovery and exploration, doctors would be stuck in a previous era of ideas and techniques. We might still subscribe to the humors theory. Or perhaps we would continue to be treating many maladies with bloodletting. Researchers on the benches of labs and in the halls of the wards have time and time again made new discoveries changing not just our understanding of the human body but the ways that we diagnose and treat medical conditions.
But if the last few years of medicine are in any indicative of advancing science, the pursuit of evidence-based medicine is a messy affair. During the COVID-19 pandemic, the publications, debates, conversations, follow up papers that normally happen in the pages of obscure medical journals, the dusty corners of university libraries or the doctor’s lounges of academic hospitals now happened on the front page of every news outlet and in the endless feeds of social media. Suddenly, everyone is an expert at quoting medical literature. And the very evidence-based practice that we seek becomes yet another example of how medicine got it wrong. And the damage is not just evidenced by the morbidity and mortality of patients but in the myriad of erroneous, but firmly held beliefs by healthcare providers and laity alike.
The problem comes when we divorce the evidence from common sense - when we hold up peer-reviewed studies as the highest authority in medicine and forget to check the findings against the background of our experience. When this happens, problems arise. While medicine has advance in some incredible ways over the course of history, there have also been an equal number of times where we have got it totally wrong - sometimes in catastrophic ways.
One of my favorite studies to discuss with medical students and residents is a 2018 paper in the British Medical Journal entitled, "Parachute use to prevent death and major trauma when jumping from aircraft: randomize controlled trial." In this trial, the researchers randomized the participants into one of two groups. Those in the first group were equipped with a parachute. And those in the second group were given a backpack. Participants from both groups were instructed to jump from an aircraft. The researchers found that there is no difference in mortality between the groups.
The authors in their discussion write, "Should our results be reproduced in future studies, the end of routine parachute use during jumps from aircraft could save the global economy billions of dollars spent annually to prevent injuries related to gravitational challenge." They continue, "Opponents of evidence-based medicine have frequently argued that no one would perform a randomized trial of parachute use. We have shown this argument to be flawed, having conclusively shown that it is possible to randomize participants to jumping from an aircraft with versus without parachutes (albeit under limited and specific scenarios)." The limited and specific scenarios that they reference can be noted earlier in the paper - aircraft used to conduct the trial were stationary and on the ground.
The point of the paper is that methods matter. How you conduct the study, what study population you choose, who is include, who is excluded, sample size, the primary outcome, single vs composite outcomes, etc., all of these can have a profound impact on the results. I like to quip that 85% of all statistics are made up. And while that number is itself made up, it is emblematic of the reality that statistics can be bent to suit the interests of the statistician.
This makes it very important, then, that we read and assimilate medical literature very carefully. With any luck, the continued march of research moves us progressively closer and closer to understanding ultimate truth. But since we as humans suffer with a lack of omniscience and are unfortunately blinded by bias or misaligned incentives, the mere presence of a PubMed ID or ClinicalTrials.gov registration number does not guarantee that what is published is accurate. As clinicians or as lay consumers of medical information, we need to be careful to appraise the findings and compare them to what we know from other data sources and our own personal experience.
References:
Yeh RW, Valsdottir LR, Yeh MW, et al. Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial. _BMJ_. 2018;363:k5094. doi:[10.1136/bmj.k5094](https://doi.org/10.1136/bmj.k5094)
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