Twisted Skepticism (continued)

Writing about advances in obstetrics, Atul Gawande, like me, suggests there is a serious downside to being methodologically “correct”:

Ask most research physicians how a profession can advance, and they will talk about the model of “evidence-based medicine”—the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers, preferably through a double-blind, randomized controlled trial. But, in a 1978 ranking of medical specialties according to their use of hard evidence from randomized clinical trials, obstetrics came in last. Obstetricians did few randomized trials, and when they did they ignored the results. . . . Doctors in other fields have always looked down their masked noses on their obstetrical colleagues. Obstetricians used to have trouble attracting the top medical students to their specialty, and there seemed little science or sophistication to what they did. Yet almost nothing else in medicine has saved lives on the scale that obstetrics has. In obstetrics . . . if a strategy seemed worth trying doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved. Obstetrics went about improving the same way Toyota and General Electric did: on the fly, but always paying attention to the results and trying to better them. And it worked.

Is there a biological metaphor for this? A perfectly good method (say, randomized trials) is introduced into the population of medical research methods. Unfortunately for those in poor health, the new method becomes the tool of a dogmatic tendency, which uses it to reduce medical progress.

6 Replies to “Twisted Skepticism (continued)”

  1. Interesting question. When I interviewed Taubes, he spoke of the importance of skepticism. But since his book was full of data I think by skepticism he meant “value data” (e.g., look at data) rather than “ignore data”. I’m not sure, though.

  2. There’s a fundamental difference between the way individual people learn and the way public policies are determined.

    People learn only through self-experimentation, in which a healthy skepticism is necessary. But if there is too much rigidity in that skepticism, novelty is discarded as anecdote, rather than clue.

    I think we can learn much from a scientific approach, but not necessarily by accepting the conclusions of scientific investigations as gospel, but rather seeing those conclusions as more data points. And the conventions of the scientific method do yield data points that have a unique, though not exclusive value.

    I think nutritional data are particularly affected by the fact that we are much more biochemically unique than Nutritional Science posits and assumes. So generalizing investigations of nutrition to larger critiques of science in general is dicey.

    I’ve been involved in this kind of nutritional self-experimentation for decades, so I’ve thought a lot about this. Coherence still escapes me, however.

  3. I’d add that trials in Europe determined that there were much better positions for childbirth than the standard one in America — more than thirty years ago.

    OBs, for the most part, stick with what is most convenient for them. /Sigh

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