A heretic essay in JAMA by Vinay Prasad (Northwestern of Chicago), Adam Cifu (U. of Chicago) and John Ioannidis (Stanford) should be required reading for every medical student and resident and to pass any board certification exam in any specialty … in my humble opinion.
John Ioannidis became one of my personal heroes with the publication of his great paper in PLoS Medicine, “Why Most Published Research Findings Are False,” and its follow-up Atlantic magazine profile (“Lies, Damn Lies, and Medical Science“). Rather than being nihilistic, Ioannidis’s essay is an elegant statistical proof that makes the simple point that bias and error are inevitable and rampant in the published body of medical literature.
Here they put away their statistical software and ask us, doctor-to-doctor, to simply consider “When To Abandon Ship,” i.e., to identify and permanently shelve those medical practices that though familiar, are in reality failed or useless to patients (but not to doctors’, hospitals’, and industry’s balance sheets). True to their previous form, they eschew formal “journal speak” and use their same refreshingly unadorned and fearless prose:
How many established standards of medical care are wrong? It is not known. Medical practice has evolved out of centuries of theorizing, personal experiences, bits of evidence, expert consensus, and diverse conflicts and biases. Rigorous questioning of long-established practices is difficult. There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products. Given this conundrum, it is possible that some entire medical subspecialties are based on little evidence. Their disappearance probably would not harm patients and might help salvage derailed health budgets. However, it is unlikely that specialists would support trials testing practices that constitute their main source of income. Instead, the research community performs studies of modest incremental value without even knowing whether the basic standards of care are appropriate.
They use examples of stenting for stable coronary artery disease (which comprised 85% of stenting procedures until the aptly-named COURAGE trial showed it didn’t help), vertebroplasty, and estrogen replacement therapy, among others. A highly-cited previous article by these authors suggested that when follow-up randomized trials are conducted on a major accepted therapy, they refute standard practice about half the time.
Authors call for greater barriers to the implementation of new devices, drugs, and interventional procedures and the requirement of large randomized trials to establish benefits before the wide implementation of new practices. (Industry-supported advocacy groups figured out long ago how to counter these efforts, though: 1. Organize patients with the condition. 2. Make the public relations case to politicians and the media that regulation stifles innovation that could help people suffering. Voila! Restrictions on funding for unproven medical technologies disappear.)
It’s a trip through the looking glass of our profession’s solipsism: the endemic self-interest, self-protection, and self-promotion that has guided the centuries-long evolution of medical practice and pervades it today — including all our professional societies, high-minded journals, jealously guarded reputations, and industry relationships. None of us wants outsiders (other specialists, policymakers, patients) to look too closely or skeptically at what we do — and the essential prerequisite to preventing that is to not look too closely ourselves. If something we’re used to doing doesn’t seem to work well, or we just don’t know, there’s always tradition, habit, or patient expectations to fall back on.
But are these barriers to self-examination just rationalizations, proxies for what is, in reality, a desire to maintain the veil of secrecy that we know will help preserve our incomes, professional turf, and what remains of our respect from the public? The final irony is that the more energetically the veil is maintained, the less respect we earn or deserve as society’s last trusted protectors of our patients’ interests in health.
The author is an anonymous physician.