A rusty tool of the trade

Questions are starting to be raised about the usefulness of some of the studies that are done, particularly when so many seem to contradict each other. Today it is possible to find ‘evidence’ to prove or disprove almost anything.

Probably the most significant tool that we have in medicine is the scientific research that underpins the basis of medical practice. Certainly over the last 50 years, the ‘explosion’ of medical knowledge has been vast. Yet at the same time, questions are starting to be raised about the usefulness of some of the studies that are done, particularly when so many seem to contradict each other. Today it is possible to find ‘evidence’ to prove or disprove almost anything.

To treat reflux, depression, or hypertension we have a myriad of different medications. Behind every proton pump inhibitor, SSRI, ace inhibitor, or A 2 blocker, there are studies to show that it is better than all its competitors. Often studies also show that each one has the best tolerability.

I am reminded of the 1980’s Dire Straits song, Industrial Disease, with the line “…two men say they are Jesus, one of them must be wrong…” Can we have evidence that multiple medications are all superior to each other or must some of the studies be wrong?

The key to this lies in the design of the study, the questions asked, and how the statistics are managed. There is another interesting facet to all of this. Quantum physics (which has superseded Newtonian physics in almost all aspects of science except medicine) suggests that the process of observation is not a static one. Quantum physics tells us that in any process of observation, the observer is not passive and that the observer influences what is observed by the mere fact that they are observing it. A simple test is to have somebody run past five people and you will get five different descriptions of the runner.

There is another, potentially more serious, aspect to the reliability of evidence. Increasingly, concerns are being raised about ties between researchers and the pharmaceutical industry. The New York Times recently editorialised on “Our conflicted medical journals”. The editorial was critical of the lack of disclosure of study authors to payments either direct or indirect from industry. The paper quoted an article published in the Journal of the American Medical Association warning that pregnant women stopping an antidepressant had an increase risk of relapsing into depression compared to pregnant women who didn’t stop the medication. The New York Times noted that most of the thirteen authors had been paid as consultants or lecturers by the makers of antidepressants, but that this fact was not disclosed.

The New York Times noted that reforms were underway at many journals to tighten this disclosure but felt that these did not go far enough.

The pharmaceutical industry has a legitimate commercial interest in promoting its products. Doctors are entitled to work for industry and be paid appropriately. However, the rest of us who may read research studies and have our practice of medicine influenced by them, have a right to know of such connections.

If scientific research and study is the primary underpinning tool of medicine then we need to be very sure that this tool remains in good working order and does not get rusty.