How Medicine Advances Redux

How Medicine Advances Redux

Randomized clinical trials (RCT’s) are the worst form of  research except all the others that have been tried. ~Sir Winston Churchill

As a rule, those who object to RCT are those whose pet ideas are disproved by RCTs. Often the response of practitioners of pseudo-medicine to the results of negative trials for their idee fixe is to try and kill the messenger. There was a case in point today.

In answer to the question “What scientific idea is ready for retirement?”, Dr. Dean Ornish responds Large Randomized Controlled Trials. BTW, I see through the interwebs that Orac is discussing the issue as well at Respectful Insolence. Orac has discussed Ornish in the past:

“…his (Ornish) claim to fame is the use of very low fat diets, along with major lifestyle alterations, to effect changes in health. The reason that I find Dr. Ornish perhaps the least objectionable is that at least he tries to do science. It’s preliminary science, and usually the controls aren’t the greatest, but it is for the most part science. My main beef with him is how he represents that science to the public.”

Ornish’s basic argument about RCT’s is the Barbie lament: RCT’s are tough. He lists a few ways complications and bias could enter into large trials concerning his favorite topic, diet and lifestyle, to make their interpretation difficult or the results negative. He seems to prefer small clinical trials since they are more likely to prove him correct:

“Paradoxically, a small study may be more likely to show significant differences between groups than a large one.”

It is true. Clinical trials on complex topics can be tough to accomplish and interpret. But the solution is not to abandon RCT’s, but work to make clinical trials better, improving the gold standard, not diluting it.

I prefer approach of the Clinical Infectious Disease, How Medicine Advances:

“Kumar et al. , whose study is published in this issue of Clinical Infectious Diseases, are to be commended for refusing to bow to any of the complexities reputed to make clinical trials impossible. In Uttar Pradesh, India’s most populous and poorest state, Kumar and colleagues sustained over 3 years the first randomized, placebo-controlled, doubled-blind trial of ribavirin for the treatment of the most vulnerable patients—children (age, 6 months to 15 years)—to be hospitalized with acute febrile encephalopathy, and they performed seroreactive testing for IgM anti- bodies to Japanese encephalitis virus. By so doing, they established that oral ribavirin, at the dosage used in their study, did not improve either early or late outcomes . By demanding scientific justification for investment in this mode of therapy, they have both encouraged searches for more-effective interventions and prevented the expenditure of scarce resources ineffectively. Both faith and science are important components of the art of medicine. We ought not to mistake one for the other.”

Medicine advances with the tools of science are used to discover an approximation of truth rather than to confirm pre-existing bias.

Points of Interest: 1/15/2014
Points of Interest: 1/14/2014

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