Writer: Husnain Mazhar, MBBS. PG Emergency Medicine
Research and clinical studies are the founding stones of evidence-based medicine. Each year, new data emerges and becomes part of medical literature. The Internet created a global ease of access, and in turn resulted in more opportunities for physicians to access, analyze, and publish their findings.
Since 1990, each decade has seen an exponential increase in the global output regarding medical literature. The number of studies being published has made it difficult for physicians to keep up with advances. One aspect of this is that physicians now need to be more analytical of each piece of evidence before applying it in their respective practices. More recently, systematic reviews and meta-analyses are dominating in types of studies being published. More than 94% of all publications in reputed journals are from only 30 countries, with more than 96% of those coming from core clinical journals.
The modern era prestige provided to meta-analysis and systematic reviews has seen an increase in these two types of studies being published. Considering the total global population, so much publications coming from a fraction of people, with studies conducted on culturally, and oftentimes genetically different groups of people, makes generalization of findings and recommendations difficult, to say the least. The fact that such generalizations cannot be made, may be seen as a blessing in disguise, as a vast majority of these publications add little to existing knowledge, and more importantly, are studies with negative results, or optimistically, inconclusive.
The quality of evidence is the prime thing being affected with the surge in publications. To answer the question, why is this so? We must look at the academic culture being cultivated in the medical fraternity. Institutional administrations prefer physicians with published studies, in an almost predatory manner. This in turn has pushed the physicians towards the race to become a published author. In order to do so, they need peer reviewed, prestigious journals. These journals, in turn, have their own policies which contribute to the culture. Review of trends of the past decade shows that certain journals preferentially allow only certain types of studies but not others. These factors combined, have resulted in decline of quality of evidence being published, which in turn results in more negative studies. As the quality of evidence declines, the problems arising are far reaching. Once published, that evidence is there to stay.
Meta-analysis is considered to be the highest level of evidence, but any meta-analysis is only as good as the studies and trials it includes. And with so many tools at the disposal of physicians, and multiple study designs to choose from, it has become possible to manipulate, – albeit only to some extent – the data towards certain acceptable goals or outcomes. Skewed results are what we receive as the outcome. This phenomenon becomes more apparent when viewed through the lens of conflict-of-interest. Recent trend is increasingly demanding proof of having no conflict-of-interest from physicians involved in the study, but the same burden of proof is not put onto the publication houses and institutes funding the research. The grim truth is that despite increasing data being published, and a paradigm shift in clinical settings, of critical analysis of any publication, hardly any evidence has been put forth that changed our fundamental concepts about practice, or any particular breakthrough. This is not to diminish the updates in knowledge and the better understanding of diseases and disease processes we now possess. But the vast amount of funding in research has yet to translate into a meaningful patient outcome.
Another rather touchy point is the poor representation of developing nations in prestigious journals. The counter-argument, relying on poor standardization protocols and lack of facilities, is very convincing, but it still fails to answer the question that there too are institutes who are striving for better, physicians trying to contribute to the medical knowledge, and those physicians deserve the opportunity to present their findings in peer reviewed journals, which is currently very difficult for them. The current culture of publications and all the associated problems it brings, is something that must not be ignored. It is hardly a surprise then to hear many physicians criticizing these practices. The problem is not being missed.The difference in the capabilities and acquired competence of the advanced nations puts them in a much better position to contribute in the already saturated pool of research, and the gap still remains, and at times widens further. With time, as more and more physicians will realize the issue, the practices may be improved. We need to create a milieu of being all inclusive, so that the evidence from the as yet under-represented makes its way into mainstream.This in no way means that research and clinical studies should not be conducted. Evidence based medicine is the future, and is the most logical way forward. All that is needed is that physicians as a group, must endeavor to improve the quality of the evidence itself. To conduct studies with strict standardization protocols and all the required vigilance. And perhaps to allocate this all important job to a select few, so that no physician feels inferior, and for a better patient outcome.