By Gus Geraci, MD
The recent record $1.59 billion lottery brings some ideas to mind.
So does the recent political climate, the bickering over the “truth” and misinterpretation of facts by leaders and their followers, which strike me as an old story that we in medicine have been dealing with for years.
The issue is: “What is the truth?” And, more important, can we find answers within the truth that we have to help patients, cure disease, improve public health, prevent disease? In a world of limited resources, can we do it in a way that is most cost effective and brings value to the population?
We as physicians have learned throughout our careers to be critical of facts as stated by others. We recognize that bias, intentional or unintentional, can creep into the most well-intentioned and passionate beliefs that we hold.
We are all interested in helping our patients. It is belief in a logical, well-thought-out solution that can blind us to one simple fact – and that fact is that in organic beings, what looks good and makes sense in design, biochemistry, physiology or any other science simply does not work.
That is why we have double-blind studies. An intervention is proposed, with an expected outcome. A statistical analysis is done predicting the expected result, the number of trials or experiments is calculated so that the results will be statistically valid.
A population of test subjects is chosen, with the hope that they are homogeneous and therefore matched in every characteristic important to the study. Then they are randomly assigned to a control and experimental group, then watched for results and the intervention is introduced.
The effects are monitored, side effects are watched, and at the end results are calculated and the finding announced. Even with all these precautions, occasionally, the rules of statistics are violated, and randomness occurs, and something “proven” through a double-blind trial turns out to be wrong.
Something can always be wrong, because, it is after all a statistical game. Like winning the lottery, it seems impossible to win (or be wrong) when the odds seem to speak for or against you, but despite those odds, people win. For example, there were three winners in the recent Powerball lottery despite the odds. Impossible wins can occur, but only if you buy a ticket.
Physicians all must maintain a healthy skepticism about facts. But at the same time, we must believe, for a while until proven otherwise, that the results of a trial are valid.
Some of us accept data immediately (early adopters), some wait a couple of years for contrary data brought out in implementation in the real world (the majority), and some wait until everyone is doing it (the laggards).
Thus it is with practice guidelines. We have levels of evidence, rules about how “good” the data is.
“It worked for me with two patients” does not a practice guideline create. We need to be careful that we do not create bias within ourselves because of our experience, because a personal result experienced is not a result carefully studied and compared, and double blinded against others.
Whether arguing politics or medicine, the logic is the same.
If pure logic always worked, placebos would never cure, but they do. There is always the randomness of large groups, and the unknown in organic beings.
Both logic and the reality of statistical variance and impossibility must always be accounted for. Sometimes the facts are slippery indeed. Facts can indeed change.
Truth is always evolving. We must evolve with it.