Canadian HealthCare Mall: Patients, Clinicians, and the Science of Investigation

30 Aug

Clinical InvestigationsA department entitled, “Clinical Investigations,” was inaugurated in the July 1968 issue of this journal. That section contained reports of clinical trials structured to evaluate efficacy of diagnostic and therapeutic modalities. As the new editor of Chest then, I was delighted to receive a gracious letter from the distinguished scientist, Dr. Alvan R. Feinstein, who commented about my choice of title. Dr. Feinstein wrote that he was pleased to see that at least one editorial board believed science could be applied to the study of man and that critical scientific methodology need not be limited to laboratory and animal research.

In that same year, (1968), Dr. Feinstein introduced the phrase “clinical epidemiology” into the medical literature and noted that many investigative clinicians had begun doing the kind of research which is described under that title. A discipline of “clinical investigation” began to develop its own scientific principles and methodologic standards. Dr. Feinstein continued his pioneering efforts, and his observations after nearly two decades of scientific leadership have now been incorporated into a superb text entitled Clinical Epidemiology.

Dr. Feinstein notes that the “architecture of clinical research” was considered by him as an alternative title for his new book. Both titles indicate that one of the authors main goals is to discuss the structure and function of research published in the medical literature. Feinstein notes, Despite all the instruction aimed at preparing students for their future careers in clinical practice, medical education today contains no specific courses on how to think critically about the research results that are constantly encountered by clinicians at private meetings, conferences and in public journals. Because of this omission, future clinicians are taught a great deal about how to practice medicine, but very little about how to evaluate the published evidence on which medical practice depends.

As a result of this startling omission in our medical school curriculum, a shockingly large number of clinicians do not have the ability to differentiate between explanatory and descriptive research. Without knowledge of fundamentals of clinical investigation, the clinician is fair game for the blandishments of anecdotal observations or distorted collections of data that are presented under the guise of scientific studies. The clinician who is not a critical reader and who places as much credence on unsophisticated studies as on excellent ones cannot practice optimal medicine, and indeed may be responsible for the initiation or perpetuation of medical myths. If you are eager to read more about medical science but do not know where to do it. You are welcome –

Feinsteins new text, Clinical Epidemiology, will, I hope, assist in correcting some of these grave current deficiencies in medical education. This volume contains a comprehensive and authoritative curriculum which can offer masterful guidance in both undergraduate and graduate medical teaching. The book should also be “an eye-opener” for nurses, statisticians, sociologists, economists, hospital administrators and many non-physicians in other disciplines. Among the subjects considered in this volume are: “An Overview of Research Architecture;” “An Outline of Statistical Strategies;”medical schools “Additional Principles of Cause-Ef-fect Research;” “Structure, Science, and Statistics in Cross-Sectional Research;” “Non-Chorot Structures in Cause-Effect Research;” and “Evaluation of Processes.” The text also provides a modest background in biostatistics which may be desirable for maximum understanding and utilization.

I fervently hope that Clinical Epidemiology will be read not only by investigators, but also by clinical practitioners and other readers of medical journals. It should be required reading in medical schools and in postgraduate training years so that “the architecture of clinical research” may be understood by younger physicians.

Iatroepidemic is a term coined by Eugene D. Robin and described in his recent book, Matters of Life and Death: Risks versus Benefits of Medical Care. Iatroepidemic denotes an epidemic caused by physicians which occurs when a practice is introduced into medicine on the basis of a fundamentally unsound idea or poorly interpreted experience. Such a practice may take hold without adequate studies to establish its efficacy and then develops a life of its own. Iatroepi-demics in recent years include superficial femoral vein ligation for pulmonary embolism, tonsillectomy in children, internal mammary artery ligation for coronary artery disease, and subtotal gastrectomy for peptic ulcers. I presume Feinstein would vigorously applaud Robin s “prescription” for prevention of these “clinical epidemics.” Dr. Robin believes that the most effective single step in preventing future iatroepidem-ics would be to modify the curriculum of medical schools. He pleads for education which will teach young physicians “how to critically evaluate medical literature.