Medical Debate Belongs in the Public Space

December 07, 2016

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..

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.

This model has flaws.

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.

This example is not meant to single out Watchman or the TCT meeting; you can substitute many new technologies or drugs and other meetings. Excitement over renal denervation, bioabsorbable stents. Cholesteryl ester transfer protein (CETP) inhibitors, dronedarone (Multaq, Sanofi), and ezetimibe (Zetia, Merck) each help define the word hype.

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?

Highlighting reality does not make me anti-industry. Cardiology needs industry support and collaboration. My patients benefit from innovation. This partnership should (and certainly will) continue. But we also need people whose careers do not depend on future support from industry to be part of the debate.

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. You test treatment A against a fair comparator and then measure a clear outcome. If treatment A is better (and it's replicated), we will celebrate with you. If it's not, the world is a better place with questioning. If a study is "underpowered" to detect a difference, that likely means there is little difference to the patient. What's wrong with saying that?

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.




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