The Future of Medical Information

Perhaps we are at an inflection point for the dissemination of medical information

Take a look at this post from Dr. Ed Livingston, a UCLA professor and former deputy editor of JAMA.

“The legacy journals are dying…”

“Blogs like Sensible Medicine are the future.”

I hope he is right; but I am not so sure. Here is a screenshot of an editorial from Dr. Harlan Krumholz, an academic cardiologist at Yale. He wrote this in 2017 when he finished his tenure as editor-in-chief of Circulation: CV Quality and Outcomes.

Krumholz made a compelling case for the death of journals. He wrote that they were too slow, too expensive, too limited, too unreliable, too focused on the wrong metrics, too parochial, too static and too powerful.

Seven years have passed from that essay. You know what Dr. Krumholz does now?

He is editor-in-chief of JACC—the biggest cardiology journal. Grin.

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My Diagnosis

Ten years ago, as a hobby, instead of bike racing, I started writing, and now podcasting, about medical studies. I’ve also co-authored more than 70 academic papers and peer-reviewed many more.

My diagnosis: the dissemination of medical evidence is a mess. In fact, I think we have regressed in the last decade.

Every Tuesday, I start searching for studies to discuss in my This Week in Cardiology podcast. During the weeks of big medical meetings, it’s easy to find studies to discuss. It’s not that easy during the weeks between meetings.

The thing is…journals publish the same number of studies every week. Which means that many, if not most, of these studies contribute little or zero to medical progress. Typical examples of pointless studies: small underpowered trials, single-center case series, or, the worst, observational non-random comparisons, which are hopelessly marred by confounding biases.

I ask myself: why would the authors spend time on such a project? The time commitment is massive; not only to do the grunt work of data collection and writing, but then submitting the paper to the journal, withstanding the many rejections, and answering numerous peer reviewer queries.

If the paper describes a new observation or important trial results, then, yes, it is worth it. I estimate that less than 10% of published papers fulfill this worthiness category. Yet it continues, week in and week out.

I think of a young learner putting in these hours to get a publication and it makes me sad. The reason trainees do this is to get a better training or faculty position—at a branded institution. It’s especially sad that being a dedicated clinical trainee is not enough.

But now, looking back after nearly three decades of practice, and one decade of academic work, I am convinced this time would be better spent doing any number of other things. Things like learning to be a better doctor, training for a marathon, reading non-medical books or working on writing or public speaking would be better than first-authoring a paper that does not increase medical knowledge.

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An Inflection Point

Dr. Krumholz and Livingston highlight the reasons Vinay, Adam and I started Sensible Medicine. It’s why Andrew Foy, Muhammed Ruzieh and I chronicle the seminal trials over at Cardiology Trials.

We recognized that medical people had almost no where to go get an independent point of view.

Indeed, Krumholz was most right about journals being parochial. The reason is obvious: the business model of journals is advertising. Industry supports medical publishing. So it’s impossible to publish an editorial exposing the flaws of an industry-supported study. Sure, a few carefully worded critical sentences are allowed, but that is it.

Proponents of medical journals will cite their gate-keeping role. Editorial judging and peer-review prevents the dissemination of bad science. You can’t just publish a preprint and let the public decide, goes the thinking. Grin. Do not read Richard Smith, the former editor of the BMJ.

Medical meetings are worse. When late-breaking trials are presented, the discussant spends most of their time congratulating the authors—even if the trial was designed as marketing rather than science.

Social media used to be a place to find critical appraisal. No more. Now the key opinion leaders, the Top People, are there to thwart anyone who dare question a trialist’s choice of comparator or endpoint. One of the most influential doctors in the US referred to anyone who speaks up as the “peanut gallery.”

Together, these forces keep medical evidence inside the metaphorical gates. I’ve heard Eric Weinstein refer to this as the GIN, or the gated institutional narrative. Left atrial appendage occlusion, tricuspid valve clipping, and ARNI drugs all provide benefit. Period. Stop asking questions. But outside the gates of the institution, people-without-conflicts look at these trials and think…really?

Thinking outside the gates is what this newsletter is for. It’s our goal at Sensible Medicine and Cardiology Trials.

Independent medical appraisal is at a severe disadvantage. We can’t offer people a prominent position at an academic medical center; nor can we expect people to attend a medical meeting focused on critical appraisal.

But perhaps the Internet and the reader-supported model gives us a chance. For instance, a handful of journalists have broken from their legacy positions to become a powerful voice. The Free Press, Racket News, Slow and Boring and Silver Bulletin have made their mark. Marginal Revolution has been there even longer.

That’s our goal too: to put critical and independent thinking out there—as normal. We give permission to be skeptical but not cynical about medical practice.

There has to be a place for such thinking. For now, it is on Substack and podcasts.

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Thanks for your support. Happy New Year. May the next year be one of clear thinking. JMM