Patients are often confused by seemingly conflicting findings of studies, or equally good doctors recommending different treatment plans. How are we to decide? Medical science is a process created by a “reality-based community” to help decide such questions. Science isn’t just hypothesis-testing with empirical observation, although that is a big part of it. It is also the consensus of a community of experts. In 1660, scientists led by Isaac Newton formed The Royal Society as the first institution designed to collect, encourage, and evaluate scientific knowledge. They published the first scientific journal in 1665 (which is still in publication). Were they ever wrong? Often! For example, for 250 years everyone wrongly believed Newton’s theory that gravity was a fundamental force of nature. And that is the point – knowledge is fallible and not subject to the personal authority of any one person. But over time, the arc of the universe of scientific knowledge bends towards truth.
There have been many improvements to the system of medical science since the Scientific Revolution. The first peer-reviewed journal was published in 1731. But peer-review as we now know it didn’t begin until the 1970s. The first randomized clinical trial occurred in 1747 (citrus for scurvy), but the rules for running double-blinded randomized clinical trials, and progressive Phase 1-3 trials weren’t systematized until Austin Bradford Hill and Harry Gold in the post-WWII era. Statistics entered medicine in the 1970s. Systematic reviews began in the late 1970s. Evidence-based medicine, as we know it today, was taught in medical schools since the 1980s.
Jonathan Rauch in “The Constitution of Knowledge: A Defense of Truth” describes knowledge as a funnel. At the top are all the guesses, the hypotheses, that drive scientific investigation. This would include (in order of increasing reliability) much of what is posted on any patient health forum every day: anecdotal “evidence” from patients; YouTube videos posted by Snuffy Myers, Mark Scholz, etc.; lab studies (mouse or test-tube); observational/epidemiological studies of patients; retrospective case-controlled studies, and systematic reviews/meta-analyses of them; cohort studies (people followed from before disease occurrence; e.g., Health Professionals Follow-Up Study, Mendelian Randomization Study). All of them are just hypothesis-generating. Most hypotheses are, and should be, wrong. Science depends on evaluating lots of hypotheses. There is no shame in guessing wrong; the only problems are when guessing stops and when one confuses a guess for a fact.
Large, well-done, and confirmed randomized clinical trials are at the bottom of the funnel; they are not just hypothesis-generating, they constitute truth in medical science. These categories were universally agreed upon after looking at which kinds of studies are likely to have conflicting results, and which almost never have conflicting results. All scientists believe in these categories; “pseudoscience” occurs when people claim to be doing science but ignore these categories. Here’s a fuller description:
Some institutions regularly GRADE prostate cancer research (NCCN, AUA, ASTRO, ASCO, SUO, EAU, CUA, PCF, and others). The institutional opinions (and not anyone’s personal opinion) are the standard-of-care. Until disproved, they constitute current medical truth. While even the best research doesn’t predict for the individual, one is foolish to ignore our best estimate.
There is no science without consensus by experts - science is a social construct. One can argue that there are and always have been objective truths, but we can only know what is in some way perceivable by humans. Did the Earth always revolve around the sun? Of course. But it did not enter the realm of science until Copernicus hypothesized it (1543), and Galileo (1609), Tycho Brahe (1573), Johannes Kepler (1609), and Isaac Newton (1687) proved it and showed how. That’s when astronomy became a science. There is no science without hypothesis-testing and empirical observers.
Part 2 (tomorrow): Loss of Respect for Expertise, Fundamentalism in Science, and Distrust of Institutions
Written by
Tall_Allen
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The “consensus by experts” has been tainted. Our society has become highly capitalistic and predatory. Everything has become a commodity, even healthcare. Money has corrupted the American medical system. Peer journals and our praised medical associations are funded by special interests. Universities are afraid of losing funding and bow to their donors and government by hiring professors who toe the line. (read the Powell Memorandum, 1971). (where have I read that before?)
100% agree! I work at a hospital, I am a nurse practitioner and I have tried to read all I can about treatment options for my husband. Money has corrupted the system! Making informed decisions on your healthcare sometimes means finding the information on your own and changing physicians that are more up to date on current practices.
You should always get the best physicians you can at the top treatment centers. Yes, they can often afford to hire the best, but I'm not sure I would call that "corrupt."
A few years ago I read in a science magazine I subscribe to that there exists what scientists in other countries refer to as "The American effect". Basically the influence of money and profit seeking colors conclusions presented in scientific papers, this to such an extent that researchers must take it in to account in their evaluations of U.S. research results.
It was a piece published in Science News. The articles are mostly summaries from well considered front line science publications. One of the most well known analogous incidents is the paying of scientists in the 1960's by sugar companies to suppress information on the role of sugar in heart disease, instead turning decades of research to focus on fats as the sole dietary element of what was becoming the leading cause of death in America. The New York Times ran a series a few years ago documenting how this was done, as well as what some of the consequences to our health has been.
I mean these kind of observations to in no way detract from your 2 thoughtful posts on science and truth. However one can't ignore the socioeconomic context that we all currently experience. The article I referenced was a fairly common sense observation by some researchers in foreign countries where most basic research funding is still done directly through governments.
In the U.S. it might still be NIH dollars that fund the research, but increasingly these tax dollars flow through private corporations who direct research either through universities or their own corporate efforts. Since the major raison d'etre for most corporations is to return a profit to shareholders, at times, they may consciously (as with smoking and cancer, or fossil fuel use and global climate change) or perhaps less consciously( as with the recent FDA approval with some arm twisting of an Alzheimer's drug that showed little to no efficacy) skew their research to meet their own no doubt very real financial exigencies.
Yet profit's bearing on what constitutes a scientific truth is not obvious to me. In the best situations these are separate pursuits. Unfortunately in our real world they easily can become intertwined where the latter is second to the first. Again, this is not a condemnation of the value of the scientific method, only that in our real world we may sometimes need to exercise our critical faculties to disentangle the real science from the merely financial.
Medical science has changed a lot since the 1960s. The mistakes and abuses you point out were corrected. That is what we expect of our epistemic institutions - to find and correct mistakes over time. Human knowledge will always be subject error -it would be unreasonable to expect otherwise. But our institutions are better over time at ferreting out those mistakes than any human can be. That is why it is vitally important to support the institutions.
I am an unabashed capitalist (I have an MBA from Columbia), and see the financial considerations more as an opportunity than as a problem. Much of what we've learned in the last 50 years came about as a result of private investment. But the government has a role to play too in keeping everything transparent and in the public interest. They also provide funding for research that no single company can afford.
I agree with you, institutions need to be supported. In terms of what we've learned in recent decades, I would also point to the Purdue Pharmacy 's blatant disregard of both scientific norms(which also need to be supported if science is to progress along the lines outlined in your posts) and the co-opting of virtually every safeguard against pursuit of profit over almost every other consideration. The health of patients taking their drug seems not to have figured in at all.
So, I would have to say that these are something other than simple errors. Financial gain seems to be at the center of much misused science. In the case of Oxycontin, institutions such as the FDA went along, allowing the incorrect labeling of a powerful opiate as being non addictive. Even to the point of assuring physicians that this was true. This strikes at the heart of the trust we need to have in the medical experts who bring all of the carefully proven and curated SOC treatments into our lives. If we acknowledge the power that money has in such a high value enterprise as modern drug development and marketing we're in a better position to evaluate the drugs and treatments that are out there. Cynicism and conspiracy theories are not the answer.
Last year 7 of the 10 largest pharmaceutical companies spent on average 37 % more on advertising and marketing than on R&D(beckershospitalreview.com/p.... As you wrote, "the government has a role to play too in keeping everything transparent and in the public interest". Clearly, the amount of money and the way that it flows through the system is compromising the government's ability to fulfill those important roles. Being well informed patients may be about the best we can do.
I agree that greed can be a big and negative factor in medicine as well as in many other fields. However, in the first place, I don't think that this is anything new. Human beings have evolved with strong urges to look after themselves and their family and friends above others. The same is probably true of most other species of animal. Reading the histories of ancient societies we find the same forces in play and the same criticisms of doctors.
But in the second place, I think that science, including medical science, has more safeguards against greed than most professions. Researchers who falsify their research in order to make more money often, and I suspect usually, get caught. They are expelled from their jobs and possibly prosecuted. Research gets reviewed before it can be published. It has to be verified by clinical trial before it can be submitted to the FDA. The trials have to be reviewed and approved by FDA scientists before a new treatment can be offered to patients.
I agree that there are too many doctors who can't be trusted. I have been treated by some of them. But most of the doctors I've seen struck me as caring and committed. And most of the ones I see are, I think, salaried rather than entrepreneurs.
But whatever the state of the practitioners, medical science itself has a LOT of review by highly intelligent, highly knowledgeable experts who have a great deal to lose if they approve trash treatments.
I am enjoying the articles, Loss of Respect for Expertise has certainly taken a huge step backwards in the last few years! I can see it within my own family.
Sadly, we see it a lot on this site. People who upload or watch a youtube video and think they know as much as virologists and epidemiologists at the CDC.
Reply to T_A "There is no science without consensus by experts - science is a social construct."
I agree with the last part of the sentence. But not for the first part, as one have to distinguish well established facts from science in progress. In the latter, dissent, not consensus is essential. Many today's truths were first thought against yesterday's consensus.
But what really makes something scientific is PUBLICITY. Does every body, every expert in that domain can make his own opinion on the matter ? This requirement is not fulfilled by RCT which do not publish raw data.
IMO medicine is not a science, and will never be, as experiments are forbidden for obvious ethic reasons.
Just as gravity was thought to be a basic force of nature for 250 years by scientific consensus, all scientific truths are fallible. I agree that dissent is necessary and desirable. But science only exists by consensus. Consensus is achieved by experts publishing their research in peer-reviewed journals and presentations at major conferences. That is true of all sciences, not just medicine.
Researchers doing RCTs are not allowed to publish raw data because of privacy concerns, but they do make masked data available to the FDA and to other researchers, including peer reviewers.
You are right, but to an extent. Till few months ago I was still a PhD student, so I had many "free" reputable resources. I had noticed one thing in my previous years, thing that it has been confirmed. In many fields there is a lack of reproducibility of experiments. Now I would have to find the article again, but two problems were at the top of the list: replicate experiments does not create "new publications" and it costs money without bringing in anything. The pressure on researchers to publish new stuff is enormous and dangerous as it can produce a lot of volume of research. I have studied in the UK but I know for example that Italy, which has always had a great Uni system, is the country that publish the greatest number of studies in Europe, and at the same time the least relevant ones. Ok, I am going off topic.
Going back to the topic, not surprisingly, psychology was the first field where reproducibility was minimal even when they tried to replicate an experiment. Around 80% of the experiments gave different results from the original published ones, and in 50% of cases even the original researchers were not able to replicate their results. But hey, psychology is more art than science (we used to say).
But surprisingly, the second field where reproducibility was very very low (when tried) was medicine. The thing drove me crazy, because on one side it becomes even more important to rely on the best sources. On the other side it opens to the possibility that even the best sources could be flawed.
Oh well, today is one of those days where I see everything dark...I hate it.
To comment on my comment...there is also another aspect, this time about "big pharma". I think now we have a lot more power than in the past...such power relies on the fact that there is also "small pharma" now 😂😂 The fact that a bunch of students with the right algorithm in mind can discover some new drugs and similar, saves us from the monopoly of the usual big ones that in the past have done many wrongs to maximise profit. I think that, for example, now hiding a discovery for profit reasons is way more difficult than in the past!
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