Trust and Medical Science

Concerned citizens will march this weekend to defend science.

Standing up for science is a worthy cause. Look at what medical science has accomplished in recent times: serious diseases, HIV, heart attack, many forms of cancer, have been tamed by the advance of science.

We need more not less science. It’s nuts to cut funding to the NIH.

But science, especially medical science, has a trust problem.

My editor at theheart.org | Medscape Cardiology asked me to write a piece exploring the broken trust.

The title of the essay is: Want More Trust in Medical Science? Embrace Uncertainty and Cut the Hype

The essay has three sections.

I first addressed the lack of skepticism among my colleagues. I argue that doctors have become a rapturous audience for medical news. We too easily accept flawed evidence. Our embrace of a flawed dissolving coronary stent and a left atrial appendage closure device serve as good examples of misplaced optimism.

In the second section of the essay, I explore the problem with overselling science. Here’s an except:

Science does not do itself. Humans—bent on having a successful academic career—do science. This means positive results can become the goal rather than the pursuit of scientific truth.

I spent three paragraphs on evangelism over screening healthy people.

It crushes the public trust to say “screening saves lives” when the evidence doesn’t support the claim. This is not a typo. I cite numerous studies that show common screening tests, mammography, PSA tests, colonoscopy, when put to the test of a randomized controlled trial, do not lower overall death rates.

The obfuscation comes when screening advocates tout lower disease-specific death rates. Viz, mammography may (slightly) lower the chance of dying from breast cancer but it has no significant effect on all-cause death. Through a colleague on Twitter, I found a wonderful quote on the folly of trying to reduce your risk of dying from one sort of disease.

“If you are a patient contemplating some screening test, and the result of that test or treatment is no measurable reduction in the rate of death at some clinically relevant later point in time, then why have the test or treatment—unless the patient, for some reason, has a desire to die from condition A instead of condition B.”

Did you know the father of evidence-based medicine, the late Dr. David Sackett, said preventive medicine displayed all three elements of arrogance: it was aggressively assertive, presumptuous, and overbearing? If I were in charge of medical education, his beautiful essay would be required reading.

In the third part of the essay, I call upon medical journal editors to help the trust problem. They could force scientists to put limitations of the study into the abstract; they could make the peer review process more transparent, and they could insist authors present results in absolute terms. This latter issue is crucial. A drug may reduce the risk of having an event by 30% relative to placebo, but the absolute risk reduction may be less than one percent.

Science advocates, in my view, would be more resistant to ideological attacks if they encouraged skepticism, reduced hype and embraced transparency.

People can handle the truth: science is supposed to move slowly.

JMM

1 comment

  1. The AF Association in the UK are pushing for screening of people over 65 for undiagnosed AF but meeting resistance on current cost grounds. Given the risk of bad blood pooling with AF causing strokes and the cost to the country of treating strokes screening is surely worthwhile?

    I count myself lucky I eventually sought a rolling road cardiac test in 2014 after diagnosis in 2011 with acid reflux. As a result I was kept in hospital and given a stent. I was deemed to be at risk of a heart attack at anytime. Given my parents and their parents suffered and died from heart disease I feel screening for me eight years ago at 65 would have been a good idea.

    I elected to have ablation for persistent atrial flutter purely based on the stroke risk. I view odds in a different way to most people. Either you have the event or not 50/50. My wife expected a new man and perhaps she will get a slightly less grumpy one once the ablation procedures have worked out fully following the procedure in February last. It is certainly not instant.

    Your posts received since June last year have proved very helpful. Thank you.

Comments are closed.