Health Through Knowledge

The Serano Group


Tuesday, June 09, 2009

A Note to Doctors About Medical Journals

Blind acceptance of medical journal articles does not work any more.

The first time I talked to a doctor about Lyme disease in 2001, he said, “If it is not in a medical journal, it is not real.” My immediate reaction was an obvious and literal one: there are a lot of things real that are not in medical journals. But I knew what he was saying;  he wanted his information validated and he did not want to deal with noise from unreliable sources. His entry bar was publication in a medical journal, preferably a reputable if not prestigious one. I suspect he tended to think that way before going to medical school and that tendency was reinforced once he got there.

Although on that day my reaction was uneasiness with the doctor’s rigidity and close-mindedness, and despite knowing better, for the most part I used his standard for deciding what to believe about borreliosis for several years. If information was not coming from a journal indexed in PubMed or a similar source, for me it was questionable information. I was so biased that when shopping for a book on a medical subject, I generally would not buy it unless the author was an MD.

Trust

Biology, medicine, and health are subjects with some science and a great deal of uncertainty. We would like to defer to science to sort what is real from what is not. But this is hard, especially in medicine and health, because there are few absolutes and great potential for manipulation by people driven by forces other than a quest for knowledge and promotion of societal good.

I wanted validated information, too. The easiest, and seemingly best way to get it was to rely on journal editors and reviewers for the vetting process.

Then, reality descended when I actually read a few papers in medical journals instead of just their abstracts or summaries. These papers were in journals of good reputation, and often on subjects related to borreliosis. It was disheartening—more than disheartening. At times I felt like a child realizing there really was no Santa Claus.

Disillusion

Behind all the fine print and grandiose academic language, usually there was very little information, logic, or analysis. The greatest offenders were often the journals with the best reputations. The most unreliable authors were often those affiliated with the most prestigious institutions and universities. Regarding Lyme borreliosis, the oft-quoted Klempner study on a treatment for persisting borreliosis was a dreadful piece of work.

Even so, to this day, despite my many disappointments, I still give a knee-jerk deference to papers published established medical journals. Unlike the MD of my first Lyme disease conversation, however, I have been able to step back and become open to other sources. I no longer limit my information sources to medical journals or textbooks. Not that this made things easy. It takes some discipline to read a paper, focus on substance, and set aside automatic deference to a supposed authority.

To illustrate the wrong way of doing things—an expedient and professionally acceptable way to evaluate is by a process like this: if information is printed in JAMA assume it is true and accurate; if it is posted on a blog assume it is unreliable and not worth your time; For everything else, judge it by where it falls on this scale.

Redemption

Automatic acceptance of papers in medical journals is bad policy. Much printed in journals is unscientific advocacy dressed up in obscure academic language and accompanied by obtuse graphics—impressive on the surface, but manipulative in its intent and content.

It is probably easier for me to transition than the typical medical professional reader. I never joined, or wanted to join, any of their clubs. My undergraduate biology department was diverted by an arrangement where medical students from Rush Medical College in their first year could choose to spend it at my college. I saw an informal club form that I did not want to join, fighting for the first row of classroom seats. That club continued on to medical school and became the MD club. Most then joined a medical specialty club. I did not join any of those clubs and I certainly did not join the medical academics club.

But still, I want to read those prestigious medical journals, or maybe just their abstracts, and accept and believe them. If it is that hard for me, it must be harder for doctors who joined those clubs. But really—we all need to grow up.

Scientific method is not all that difficult to understand. Most of us leave grade school knowing its essence. That said, it takes time and mental effort to read a journal paper and analyze what is really being said, undistracted by journal name, authors names, and self-promotions in the abstract, introduction, and conclusions. We all need to make the effort, particularly with medical subjects. Put simply, it is irresponsible to accept journal papers uncritically or rely on editors and reviewers for qualification.

Evaluating a medical study does not restrict readers to be completely logical and linear, discarding their prior knowledge and observations. It is entirely appropriate for a reader to use what they know about the authors, their past history, and motivations. Just be certain you have your facts straight.

If there are other medical or even scientific areas where the literature has been manipulated as greatly as it has in Lyme disease, I do not know of them. All indications are that a small group of misguided individuals looked at the realities of Borrelia burgdorferi infections in the 1980s and decided their careers would go better if they promoted and campaigned for a paradigm that satisfied what they wanted from the world instead of advancing what is known about the disease. There was no a conspiracy, but something much more insidious: the transition of extreme, irresponsible policy into everyday business.

We know it is hard to give up cherished, ingrained beliefs. But we are optimistic about the possibilities of transformation. The Serano Group intends to work to transition professionals away from the false comfort of uncritical acceptance of medical journal articles and rote repetition of flawed dogma. Making this transition is a responsibility you owe yourself and everyone else.

Resources

Many papers in Nature and BMJ have obvious and significant errors.

Posted by Joel Spinhirne
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