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APRIL is the cruellest month, breeding 
Lilacs out of the dead land, mixing 
Memory and desire, stirring 
Dull roots with spring rain.
T.S. Eliot, The Waste Land


Spring in the great lakes region gives us renewal; the snows melt and the green returns to the land. Not the ever-present dull green of tropical climes which languishes in perpetual middle age, but a vibrant rebirth which refreshes the ground, our bodies and our minds.

My homage to intellectual renewal this year is to go back to original source documents and try and reestablish in my own mind some pillars of wisdom – stakes in the ground as it were – that have profoundly influenced my thinking. Jefferson’s Declaration of Independence is one such document, a flawed genius with some unflawed ideas, the poet of the revolution and John Locke’s heir apparent. An American student who finishes the 8th grade and cannot recite the opening paragraph of the Declaration has been robbed of an essential heritage. Then there is the Constitution, a document with vision unmatched in western civilization since the time of Lycurgus and Solon. We ignore this document at our own peril. The wording is direct and understandable. It leaves open the possibility for political evolution, but amendments must reflect the will of the people – what a concept.

No diffidence, no chicanery. Does the Gettysburg Address belong in the pantheon? I think it does. Lincoln spoke for two minutes and summarized our beliefs, our hopes and our desires. His triple rhythms of emphasis (“Of the people, by the people, for the people”) reflect an almost messianic adherence to the existence of a free people. Its self profession of its own limitations only exalts its words toward the aim of remembering why we exist as a people. Brevity is the soul of wit, and a reread of such brilliance is well worth your two minutes.

I now put forth for your consideration a document that is not often discussed, let alone placed on a pedestal. How many of you have recently reviewed the late Dwight D. Eisenhower’s Presidential farewell address given January 17, 1961? I challenge anyone to bring forth another president’s departing words which had such long term profound prophecies and warnings. He is the last President who did not have a pollster. Why? Because he defeated the Germans and the Japanese and was a part of saving the world.

Couldn’t care less what you thought; he was going to do what he thought was required by his oath of office. He was the President who, long before the civil rights act was passed, backed up integration with guns.

Everyone who comments on the farewell address realizes it is a melancholy piece. It is not a hoo-rah America piece; it is not a God bless America piece. It is both pensive and, looking back, profound. His negative views on the American hegemony and the military industrial complex are legendary, especially in light of the fact that he was the last five-star general to be elected president. What is overlooked are his views on science and technology that we are still struggling with today.

“In this revolution, research has become central; it also became more formalized, complex, and costly. A steadily increasing share is conducted for, by, or at the direction of, the Federal government…The prospect of domination of the nation’s scholars by Federal employment, project allocations, and the power of money is ever present and is gravely to be regarded.”

Amen brother.

Who’s research agenda is it anyway? How are we going to come back into line with an intelligent level of programs that actually benefit the American people as we are heading into an economic abyss? Research that puts the people further into debt helps no one. Because the underlying interest of these minions of the federal government is to get “funded,” false questions are raised and straw men are set up as targets.

Again reviewing history, remember the release of the “miracle of steroids in c-spine injury”? It was released just when the agency involved needed funding. It was a publicity stunt and was later proven wrong. Bad science is still bad science. To finish Ike’s thought: “Yet in holding scientific research and discovery in respect as we should we must also be alert to the equal and opposite danger that public policy could itself become captive of a scientific-technological elite.”

A news-starved media picks up anything and blows small tempests into large tea cups. Do you remember the “cranberry scare”? Some federally-funded researcher found cancer in mice who ate too many cranberries. Turns out that the average 70 kg person would have to eat 10,000 lbs of cranberries to equal the per kilogram equivalent of what the mice were fed. That’s a lot of Thanksgiving dinners. I could go on infinitum to the point of reductio absurdum, but enough is enough.

We need a research agenda that recognizes real costs and real limitation. I’m sorry we don’t have the financial resources to study every project that people who make a lot of money on such research view as worthy. We need to focus.  

Applications research (in which the British outshine us) is the key. What actually makes a difference in outcomes? Where’s the bang for the American tax payer’s buck? Most of ACLS didn’t work, but it took us an awfully long time to find out. Sometimes doing less is doing more and we need to recognize that fact. There is no moral obligation for this generation to solve every medical problem that has ever existed, let alone invent problems of dubious validity to make employment for certain people. We used to supplicate in front of the alter, now it’s in front of the mass spectrometer. What we need is research in line with our needs and resources, not continued proliferation of make-work jobs. Scholarly entitlement must end. Maybe we should start publishing anonymously. Maybe that would cut down on the number of useless papers that are submitted. The uniquely toxic combination of financial lust in the eyes of researchers and the sugar daddy mentality of the federal government needs to be called into question. Big government can and should be viewed as just as dangerous as “big pharma.” Remember, these are the same people who brought you the Vietnam war and recorded record deficits your children will never repay. We have had common sense propagandized and educated out of each and every one of us. By the way, could you please pass the cranberry sauce?

Quis custodiet ipsos custodes?
[Who watches the watchers?]
-from Satires, by Juvenal
   

To be continued next month...

Have a question for Dr. Henry? Leave a comment or pose a query here or on twitter @epmonthly or email This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Comments   

# Rogue Medic 2012-04-02 19:48
The best check on misbehaving scientists will always be other scientists.

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Reply
# Poor consumerism is as much to blame.PGY 10 2012-04-04 14:53
Dr. Henry,
Thank you for this thought provoking article.

While effectiveness research is one way of stripping away useless tests and treatments, the responsibility really lies with us as clinicians being better consumers of clinical trial data. We all heard this in residency when journal club was meant to foster those skills but it was mostly about some beer and pizza. Most of the studies that have introduced a drug or device into our practice are without significant improvement in outcome. Look at the statins, tpa, or plavix examples; the overall change in outcome was minimal. If we as consumers did a better job of expecting a certain size of effect to change our practice pattern then we would look for that in a study and reject it not for the p-value but because it didn't meet our inherent criteria of changing the outcome enough (i.e. an effectiveness value). Now the NNT or NNH is meant to assist with this but how many articles report these and how often do you think about why we don't report the NNT interval to better explain our confidence in a treatment? In this example, the editorial and peer review process has let us down. I shouldn't have to calculate the NNT in a study and then calculate the NNH to come up with my own calculus to determine if the risk:benefit ratio is sufficient to change practice. The journal reviewers instead are concerned with the readability of the article and not alienating the readership with 'fancy' statistics while an obscure and outdated p-value is embraced. We as trained physicians have given up on being sophisticated consumers and we can blame ourselves for allowing large studies with equally small effectiveness change our practice.

On a side note: the research from NIH is driven by RFAs which are designed by senior NIH members who are often on advisory boards to Pharma and Device manufacturers so lets not think that NIH is of,by,nor for the clinician. We as clinicians sit silently in the research agenda process while those interested in developing and marketing intellectual property are driving the research train straight into a course aiming for financial prosperity. We need to be more skeptical and less embracing of clinical trial data that never shows adequate effectiveness in the first place and instead try to think more scientifically about our practice.
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# authorgreg henry 2012-04-09 10:59
Pgy 10 I loved you response."We have seen the enemy and he is us." You make some excellent points about things we all know but are afraid to ask because we don't want to hear the answer. You seem to have some insight into these problems and I here by invite you to write a guest response or OP-ED piece and we will get it published. Greg
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