Diagnosis: contemporary medical hubris; Rx: a tincture of humility

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Blackwell Science, LtdOxford, UKJEPJournal of Evaluation in Clinical Practice1356-1294Blackwell Publishing Ltd 20051212430Original ArticleDiagnosis: contemporary medical hubrisS.J. Genuis

Journal of Evaluation in Clinical Practice

doi:10.1111/j.1365-2753.2005.00599.x

Diagnosis: contemporary medical hubris; Rx: a tincture of humility Stephen J. Genuis MD FRCSC DABOG Associate professor, University of Alberta, Edmonton, Alberta, Canada

Correspondence Dr Stephen Genuis 2935-66 Street Edmonton Alberta T6K 4C1 Canada E-mail: ([email protected]) Keywords: evidence-based medicine, iatrogenic illness, medical education, medical research, medical professionalism, pharmaceutical industry

Accepted for publication: 14 January 2005

Abstract Despite increasing attention to evidence-based medicine, unprecedented advances in medical technology, and rapid diffusion of innovative information, there continues to be disturbing disclosures of widespread iatrogenic illness resulting from harmful medical interventions. The medical community at times displays a lethargic and lackluster response to important scientific and epidemiological data that challenges prevailing conventional wisdom or that elucidates existing medical miscalculations. To ensure that long-term health and well-being for patients and the community remains the primary goal of medicine, it is necessary to revisit the important issues of scientific integrity, health care objectives, and medical professionalism. Furthermore, to be trustworthy advisors for individual patients and credible advocates for the health of populations, the medical community needs to critically evaluate the profound influence of commercial interests on medical research, medical education and clinical practice.

One of the greatest pains to human nature is the pain of a new idea. It . . . makes you think that after all, your favorite notions may be wrong, your firmest beliefs ill-founded . . . Naturally therefore common men hate a new idea, and are disposed more or less to ill-treat the original man who brings it. Walter Bagehot (1826–1877) ‘Physics and Politics’

On my first day of medical school it was difficult to appreciate the words of an unorthodox professor who claimed that 50% of the dogma that we, as medical students, would learn in the next four years would subsequently be proven to be dogmatically wrong. As an excited neophyte I naively assumed that I had signed up to learn a collection of facts, figures and therapies that would contribute to saving the world from disease and suffering. Witnessing numerous flip-flops on sacrosanct scientific tenets after donning my graduation robes, I now appreciate that the professor’s words were not only strangely 24

prophetic, they represent the prototype of medical progress through the ages. As we continue to modify our teachings in response to credible research that uncovers and exposes advances as well as flaws in health care and medical science, the medical community should encourage scientific curiosity, pursue a vigilant stance of scientific integrity, and guard against the appearance of arrogance. As was common in that era, more than one in four women coming into the General Hospital in London in the mid-nineteenth century died following childbirth. Although many throughout Europe accepted this typical brutal rate of death as an unavoidable obstetrical complication, Dr Ignaz Philip Semmelweis, a Hungarian doctor working in Vienna, noted that women who delivered without doctor or medical student care did not have the high death rates of those parturients with doctor-assisted deliveries. It became apparent that some contagion was being directly transmitted to pregnant women as medical staff went from dissecting in the anatomy department to examining women in the labour and delivery room without washing their hands in-between. When Dr © 2006 Blackwell Publishing Ltd

Diagnosis: contemporary medical hubris

Semmelweis introduced a simple hand washing protocol, the rate of death plummeted to a little over 1% (Monif 1982; Spirer & Spirer 1991). Although he documented his findings carefully, the medical establishment – with pre-existing dogma to explain puerperal fever – rejected him and his research; countless women paid the ultimate price. Like many other examples throughout medical history, several years passed before conventional wisdom was reversed, before the doctor community achieved consensus and before new protocols were implemented. Reflecting on the sometimes tepid response from the scientific community to health research which challenges prevailing wisdom, three questions spring to mind. First, in our technologically advanced 21st century, do there continue to be therapies and public health strategies in routine use which are either ineffective or which frequently cause serious harm to patients? Second, in a paradigm of systematic evidence-based medicine (EBM) how is it possible to still have harmful management strategies in routine use by doctors and public health personnel? Finally, what might be done to minimize continued use of sub-optimal interventions, thus reassuring the public regarding medical credibility?

Retakes in medical protocol In the contemporary age of rapid information transfer, queries about the performance of some medical practitioners and the therapeutic benefit of various standard therapies are increasingly evident. Data are accumulating about troubling rates of iatrogenic illness, a concern that challenges the fundamental ‘non nocere’ (do no harm) principle (Leape 1994; Nettleton 1995; Starfield 2000; Moore et al. 2002; Barbaresi 2003; Zhan & Miller 2003). Medical errors, adverse drug reactions and nosocomial infections account for sobering rates of morbidity and have become major causes of mortality (Leape 1994; Classen et al. 1997; Lazarou et al. 1998; Green et al. 2000; Steele & Fawal 2000; Thomas & Brennan 2000; Juntti-Patinen & Neuvonen 2002; Onder et al. 2002; Weingart & Iezzoni 2003; Zhan & Miller 2003; McGavock 2004). Media attention and increasing public awareness of these trends have prompted further research into iatrogenic etiology for disease.

With increased scrutiny and recent research into the efficacy of medical therapies, suspicion is rising that many routine assumptions, procedures and management protocols do not always serve the best interests of patients. Ultimately, it is impossible to know how many individuals have been irrevocably harmed by various accepted interventions, but even within the last few years, troubling information has come to light. The elucidation of dangerous sequelae associated with widespread hormone replacement therapy (Chen et al. 2002; Herrington & Howard 2003; Shumaker et al. 2003; Wassertheil-Smoller et al. 2003), the cardiac valvular damage frequently resulting from widely used diet-drug cocktails (Tomita & Zhao 2002), the correlation of certain ubiquitous anti-inflammatory therapies with serious cardiovascular disease (Fitzgerald 2004; Topol 2004), the finding that antidepressants in youth ‘may worsen depression or trigger suicidal or aggressive impulses’ (Kondro 2004), and the link between commonly used calcium channel blockers and increased cardiovascular mortality (Wassertheil-Smoller et al. 2004) provide recent examples that illustrate the need for vigilant scrutiny of existing medical dogma and remedies. On the horizon, it is possible that numerous other theories and therapies currently espoused by conventional medical thinking will be found lacking by forthcoming research, particularly as there is increased awareness of late that dissemination of research information demonstrating harm or ineffectiveness has, at times, been suppressed by industry (Healy 2002; Olivieri 2003; Kondro & Sibbald 2004; Lenzer 2004a,b; Sibbald 2004). Yet, has the medical establishment embraced meticulous scrutiny of doctor practice patterns and supported those who uncover and expose serious flaws in existing medical management? Two recent examples suggest that the frosty attitude of the scientific community towards new ideas and challenges to existing scientific tenets may not have changed much from the time when Semmelweis and other upstart health pioneers were ostracized for their perspicacious vision on medical matters. The lethargic response following release of research revealing the microbial etiology of peptic ulcer disease – including the arduous and slow process of getting the research published, achieving consensus within the medical community (NIH Consensus

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Conference 1994), and then soliciting practicing doctors to actually use the information – led one of the principal researchers to query whether devotion to ideology was more powerful than scientific fact in the medical community (Marshall 2002). The apparent chill recently experienced by Ugandan President Yoweri Museveni and his health officials, upon diffusion of information related to a novel public health programme in Uganda addressing the HIV/AIDS crisis – is yet another example. With his ‘social vaccine’ initiative (Hogle et al. 2002), the rate of HIV in Uganda has dropped from reported rates as high as 30% in 1992 (Uganda 1999; Feuer 2004) – the highest in the world at that time (Feuer 2004) – to about 5% in 2002 (Hogle et al. 2002). Rather than being hailed for saving the lives of millions of ordinary people and rather than the programme being embraced as a model for other nations devastated by AIDS, Museveni and his initiative have been the recipient of considerable derision and scorn (Kaiza 2004; Museveni 2004). With apparent resistance to change and a vilification of the agents of change, it appears that contemporary human nature may be no more enlightened than existed in the days of Semmelweis, and that excellent outcomes may be no match for age-old human fixations such as pride, passion, politics, and pocketbooks. Notwithstanding human frailty, however, how can health policy or prevailing medical wisdom continue to be seriously astray in some areas within the purportedly systematic scientific paradigm of EBM? The hijacking of evidence-based medicine Over the last decade, most undergraduate, postgraduate and continuing medical educational activities have become increasingly steeped in the EBM approach to health care (Straus & Jones 2004): providing evidence-based clinical interventions will result in better outcomes for patients. It appears intuitively reasonable to conclude that delivering credible research-based medical care is more likely, on average, to be successful than using spurious unsubstantiated remedies. Accordingly, it seems incongruous to some that within the allegedly methodical and disciplined paradigm of EBM, there continues to be numerous dubious management strategies in routine use by medical personnel. With 26

many concerns expressed in the medical literature regarding the practical effectiveness of the EBM approach (Miles et al. 2004), among the most pressing issues related to EBM is the credibility of some of the ‘evidence’. An abundance of recent commentary from various sources casts aspersions on current clinical research as well as the reporting of various clinical studies. As escalating numbers of researchers, faculty members and academic institutions have financial ties to commercial interests whose wares they are investigating, there is increasing skepticism about some of the ‘evidence’ that is published and used as the basis for decisions in medical practice. With the recent finding that favourable product recommendations are found disproportionately in clinical research funded by product manufacturers (Lexchin et al. 2003), various medical editors have brought considerable attention to the current research paradigm wherein industry often influences the research questions that are chosen, methodology of studies, data analysis, whether results are published, and dissemination of results (Relman & Angell 2002; Angell 2004; Horton 2004). For example, two former principal editors of the New England Journal of Medicine recently concluded that academic institutions are increasingly being engulfed by the pharmaceutical industry as ‘virtually every research-intensive medical centre in the country now has contractual ties with one or more drug firms’ (Relman & Angell 2002). As a result, medical trainees are often taught and mentored by experts who are often personally involved in industry research and product promotion. Furthermore, medical staff at all levels read potentially tainted information about the efficacy and safety of various interventions. The reliability issue becomes compounded as further research and trials in medicine often build upon the findings and conclusions of existing evidencebased research which, it now appears, may have uncertain credibility. Clinical Practice Guidelines, commonly seen by clinicians as authoritative, are also crafted from allegedly evidence-based research and it has also become apparent that such guidelines, not infrequently, are being indirectly funded by industry through grants to individuals and to illness-specific foundations (CMAJ Editorial 2003). It is through the dissemination of such research findings and practice guidelines, often at medical education forums by

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industry-funded ‘thought leaders’, that sincere practitioners receive what is termed evidence-based information from which they choose interventions for their patients. Furthermore, the EBM vernacular has been usurped to some degree by commercial enterprises and is skillfully tossed around with doctors. Industryfunded medical magazines, look-alike pseudojournals and other publications arrive routinely in doctors’ mailboxes using evidence-based jargon to keep recommended treatment protocols and product names foremost in the clinician’s mind (Rochon et al. 2002). For example, an industry-sponsored publication entitled ‘Hormone therapy for post-menopausal women in the new millennium’, advertising benefits of hormone replacement therapy, was recently distributed to doctors throughout Canada with the heading ‘Linking Evidence-based Medicine to Clinical Practice’ (Jolly et al. 2004). With no specific author cited and the pictures of five cardiologists on the front, a recent four-page industry-sponsored bulletin promoting the benefits of lipid-lowering therapies carried the headline ‘Evidence-Based Medicine: Turning clinical research into medical practice’ (Leiter et al. 2004); the sidebar explained that the communiqué was designed to provide ‘physicians with the latest in clinical thinking and therapeutic practice’ and reflected the views of those pictured (Leiter et al. 2004). With concern about the utilization of medical literature for commercial gain, Dr Richard Horton, editor of the Lancet, recently stated that some medical publications ‘have devolved into information-laundering operations for the pharmaceutical industry’ (Horton 2004). Although the merits of EBM should not be measured by its abuse, there is a big disconnect between the ideology of EBM and its actual outworking; the sincere attempt to improve patient outcomes via evidence-based medical practices has, to some degree, created an ingenious marketing tool for industry. With mounting volumes of dubious industryfunded research and information diffusion techniques calculated to influence prescribing behaviour, it is not surprising that some recent therapies in common use have been found to be ineffective or to possess risks that significantly outweigh benefits for unsuspecting patients. At this juncture in medical history, it is important to consider avenues to minimize

the use of adverse therapies, to facilitate discernment of the medical literature, and to promote beneficial practice patterns among doctors.

Quo Vadis The amalgamation of a public fascination with health matters and an information age complete with global cyberspace gossip has produced increased scrutiny of medical practice in general. It is unavoidable that with prevalent accusations of diminishing medical integrity and professionalism (Misch 2002), with major reversals in medical recommendations, and with ‘claims and complaints against doctors . . . growing worldwide’ (Vass 2002), that many suffering patients have queries about the reliability and performance of the conventional medical community. As a result, there are now more visits annually in America to complementary health practitioners than to conventional primary care doctors (ACOG Bulletin 2001) with out-of-pocket expenditures in the United States for complementary and alternative therapies in 1997 reaching $27 billion, more than the total expenditures for all doctor services nationwide in that year (Gallo et al. 2001). Many volumes discuss strategy to address challenges in the medical community; two thoughts will be highlighted here: (a) integrity in research, reporting and education; and (b) re-evaluation of objectives. First, ongoing modification to medical doctrine and the continuous unveiling of the intricate workings within the human species will continue only as long as there is credibility in scientific research, trustworthiness in reporting of evidence and responsibility in the dissemination of information (Altman 2002). Specific safeguards are required to ensure integrity in research and education and to assiduously monitor the influences of commercialization. The primary underlying objective of medical research must be to further the health and well-being of individuals; the focus of doctor training must be the diffusion of knowledge to assist colleagues in achieving optimal wellness for each patient. Notwithstanding the benefits of full disclosure with regards to industry affiliation, researcher neutrality may well be an oxymoron when the livelihood and career aspirations of the researcher are tied to industry funding.

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An international registry with strict criteria for clinical trials may be required and non-profit institutions motivated by public interest need to stay in the business of conducting medical research (AlsNielsen et al. 2003; Moynihan 2003). Ethical industry is an invaluable component of our society; it is not the role of industry, however, to be primarily responsible for research on health and therapeutics (Angell 2000) which, if done appropriately, might minimize the need for their own products and services. Agencies and licensing bodies responsible for the health and welfare of the population must ensure that conflicts of interest be avoided in medical research and education. Second, medical development is a work in progress and in order for credible advancement to continue, it is necessary for individuals and institutions to accept that conventional wisdom is often less than optimal and to remain un-threatened by innovative ideas or unanticipated information. Scientific progress and ultimately all wisdom entail the continual unearthing of our own ignorance. As professional facilitators of health, doctors should recognize their limitations as well as their abilities, and not be loathe to challenging fundamental assumptions, to scrutinizing practice patterns, to considering credible evidence, and to embracing change. Likewise, medical students and residents should be trained to critically think as well as to studiously learn; to continuously evaluate current practices rather than religiously abiding by the status quo. Amid escalating public dissatisfaction with the medical establishment and widespread accusations of arrogance, it might prove valuable for some constituents of the medical community to review individual and collective objectives of health care professionals. Utilizing varied therapies and procedures such as aligning fractured and displaced bone segments, health providers facilitate the instinctive inclination of the human machine to protect and restore health, but humility compels us to remember that it is nature, not us, that works the wonder of healing and physical regeneration. The exquisite complexity of the human body has much to teach us, and earnest scientific curiosity with reasoned thought, rather than adherence to the prevailing herd mentality, will facilitate learning, medical progress and ultimately the health of our patients. 28

Conclusion There is so much about health that we do not understand, and history bears witness to the many times that the medical establishment has reversed its stance on dogmatic beliefs regarding health matters. The recent realization that various medical interventions are directly contributing to the burden of illness has contributed to accruing concern regarding medical integrity and professionalism. Despite the commendable objective of discerning therapeutic fact from fiction, the success of the EBM movement has recently been thwarted by major concerns related to integrity in research, reporting and information diffusion. With diminishing public trust, ever-present accusations of arrogance and an escalating number of desperate people giving up on classical medicine, the medical community should respond with a renewed emphasis on integrity, humility and professionalism.

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