We need to talk about who gets to speak publicly and where
medical debate should happen in 2016.
Here are bothersome excerpts from comments posted in
response to a commentary on left atrial appendage occlusion for the prevention
of stroke in patients with atrial fibrillation:
"I believe that
the proper medium for scientific discourse is through the peer-reviewed process
of scientific publications in medical journals and abstract presentations at
national/international conferences."
“For an individual physician to state an opinion-verdict
regarding a decade-long, robust, scientific process outside the confines of a
peer-review process is, to put it mildly, professionally irresponsible.
Patients will read this editorial. Few may understand the difference between a
physician's opinion and a medical fact, but the majority may not!"
"I consider this type of article as an opinion piece.
[It] is scaremongering and is totally unhelpful when published and promoted in
a widely available online medium read by uninformed physicians around the
world."
I reject these ideas. I will make the case that scientific
debate belongs in the public space.
I will not argue against peer and editorial review of
scientific work. This is a vital part of science. I participate in peer review.
I've seen it improve papers. But peer review is only one (imperfect) way to
discuss medical science.
Publication of science in a journal should not be the last
word. Rather, it begins the debate. Clinicians (and now patients) must assess a
study's conduct and the relevance of its questions, findings, and authors'
conclusions. Clinical translation depends on postpublication discourse. In the
past, these debates were held behind closed doors, and the same people who
performed and judged the studies wrote the guidelines. Industry, too,
"assists" in translating the evidence.
The first problem. Too many of the discussions at medical
meetings resemble marketing more than science. Exhibit A is the session at the
Transcatheter Cardiovascular Therapeutics (TCT) meeting 3 months ago in which
the latest Watchman (Boston Scientific) data were presented. Recall that this
was a nonrandomized nonadjudicated series of safety events reported by industry
reps present on the day of the procedure. The discussion I heard featured zero
critical appraisal. Each expert spoke warmly of the study. Then the flawed
paper passed editorial review of the leading cardiology journal…
The second problem. Conferences are hardly designed for
robust discourse. Spirited debate is uncommon. More often we get choreographed
sessions with little time left for dissent, and little dissent is tolerated.
Also a factor is that fewer independent dissenters pay their way to meetings.
Discourse is muted in journals. Jargon-free dissent is rare.
More common is tepid, careful journal-speak. You can almost sense that an
editorialist knows that too much clarity jeopardizes future opportunity. What
do you expect when the print version of the journal comes wrapped in an
advertisement? And that same company provides grant support for future
research?...
The third problem. Fear of public critique of medical
science confuses contrarian opinion with nihilism. The numbers I use in my
essays are fact-checked. I combine reported data with my experience in clinical
medicine to form an opinion. You can disagree with the opinion—many do—but to
say or imply that it's unprofessional or potentially dangerous for patients to
hear something other than the anointed opinion typifies the paternalism of the
past. Far worse than paternalism, though, is the misthink that an invasive
procedure or drug is all that we can do to help fellow humans. Caring for
people does not require a device implant or a drug prescription.
More than ever we should encourage skepticism and debate
among our patients and colleagues. Great scientific results stand on their own. Anyone should be able to see
superiority in tables 1 through 3 of a publication. Clever composite end
points, noninferiority testing, secondary analyses, lengthy discussions, or
editorials should induce caution…
The digital revolution delivers influence to new groups of
experts. Doctors who see patients every day, independent researchers, patients,
anyone with good ideas now has a voice. These changes in the democracy of
influence don't replace peer review or debate within the confines of academia;
they add to it. Scientific discourse already occurs in the public space—with or
without us.
Disagree with ideas, but don't say we need to speak
privately. From now on, the debate is in the open.
http://www.medscape.com/viewarticle/872949
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