What We Know, What We Think We Know, and What We Don't Know

Hundreds of pages of scientific writing come across the desks of journal editors weekly. Some few articles are brilliant and represent new findings that will change medical practice and save countless human lives. Some represents a restating of information that has already been identified. Some can be charitably termed weak science that, if incorporated into the psyche of practitioners, does more harm that good. Some is fraud. How is an editor to know which category a particular document belongs in and whether, for any reason, it is justifiable to publish the document at hand?

In a recent gathering of the Editors in Chief of the largest medical journals these important aspects of their work were discussed in open forum. Of course, consensus was reached on nothing as would be expected. But the editors noted an increased recognition of fraud and bad science in submitted documents. The level of technological sophistication in the publishing industry allows more sensitive screening of articles submitted for publication but even with a raised awareness of studies that purport to demonstrate findings that they do not can and will slip into publication. As you might imagine, having to retract journal articles reflects badly on the editors and many expressed consternation at the current circumstance.

An example of the phenomenon of inaccurate or fraudulent information driving clinical practice occurred in the late 90s and early 2000s when a single practitioner, mostly in a single but very well respected publication, produced what appeared to be irrefutable evidence supportive of a method for providing postoperative pain control. Unfortunately many of the trials were not IRB approved, some may have been partially fraudulent, and some were entirely fraudulent. Most of these papers were eventually retracted, however, those data changed practice for some prior to being retracted and may have had an impact on the interpretation of other similar studies. What are we to make of this? Personally it has caused me to change the way that I analyze the information that is published and I would offer these soft rules that I have adopted:

1.    Be suspicious of all medical literature, especially that which purports to support great and rapid leaps in knowledge and clinical practice. Civilization moves slowly. Profound discoveries that reverse practice require time to be validated.

2.    Never change practice on the basis of one observation or one miraculous study. See above.

3.    Be suspect of any single investigator or group that publishes more than 5 -10 papers over a two-year period. It is simply impossible to publish as many scholarly articles as some seem to be churning out.  Think to yourself: Is it reasonable to believe that all of this science could possibly come out of a single group in such a short period of time?

4.    Understand that journal editors are human and that mistakes will be made. Do not interpret the fact that something was published as an assertion that what is written should be accepted to the letter. The review process post publication has eviscerated many dramatic studies

The information that we read can be accepted as inviolate fact, can be rejected out of hand or can be viewed with a jaded eye. In fact, some of the information that we accept as fact and go to some trouble to teach in 2015 will be demonstrated to be inaccurate, incomplete, or worse in 2018. Virtually nothing that I learned as a resident has stood the test of time, although it is still considered to be reasonable to use oxygen in many clinical situations. How then is one to practice medicine?  In terms of maintaining our knowledge and our sanity, following the concepts above may help. In general, following the precepts that are suggested by the guidelines from our professional organizations will likely put your practice in the mainstream. This information is reviewed and the data are graded on a regular basis. More than on the cutting edge, that is where most of us should be practicing.

Rae Brown, M.D.