It's only fair to share…

Much is made of the evidence base of modern medicine. It is certainly the case that many trials are done and that to bring a pharmaceutical to market requires trial evidence to show that the drug is better than placebo and that side effects are acceptable.

There is one catch in all of this. Who determines the quality or lack thereof, of the evidence. It has often been quipped in semi jest that the best part of evidence based medicine is that you can find evidence for just about anything you want. This does not mean the concept is flawed. It does mean that its application is.

It is also worth noting that there are different forms of evidence aside the double blinded placebo control trial which only lends itself to certain types of inquiry. In fact the so-called “gold standard” double-blinded trial was originally designed to assess safety and not efficacy.

Issues with the non-publication of trials which didn’t get the “right” result and of ghost writing have been made public over the last few years but it is difficult to ascertain what difference this has made. Who is going to delve into trial registration documents and cross match to see if a trial has not been published?

But now another problem has raised itself. A review of abstracts from randomised control trials published in top psychiatric journals from 2012 to 2017 found that over 50% included some form of spin. Some 56% of trials failing to reach statistical significance on their primary end point still claimed the treatment to be beneficial. Some moved the focus from the original aim of the trial to make it look more positive.

Similar findings of spin have been observed in oncology and cardiology trials. It is worth noting that funding was not associated with the presence of spin. This suggests that, as has previously also been noted, there is a strong positive bias in trials.

Researchers want positive results and will tend to find them. This is human nature. However, the concept of peer review is supposed to guard against this. In reality peer review has become little more than getting your mates to put an elephant stamp on your paper, usually on the understanding that you will return the favour. This is also not restricted to medical research.

Stanford Physician John Ioannidis noted in 2016 that most medical research was not useful meaning it did not “make a difference for health and disease outcomes”.

Building on the theme of spin Jacob Stegena of Cambridge writes in a new book called Medical Nihilism that, “Everybody wants positive results. Patients are desperate to be cured and prone to the placebo effect. Journals are eager to publish good medical news, journals and mass media to publicize it and the public to read it. Researchers can gain grants, glory and tenure by showing that a treatment works”.

This is true. He also notes that in times past doctors were less enthusiastic about the benefits of treatments and that silver bullets are rare. Antibiotics work well against bacterial infections and insulin is a life saver for those with type one diabetes. Yet many medications for type two diabetes, cholesterol and depression have little impact on life expectancy, all-cause mortality and in many instances not much impact on the condition being treated.

Sadly, ideology drives more health research, funding and treatment than anyone cares to admit. Screening mammography has had negligible impact on breast cancer mortality yet continues to be promoted to women who are often not fully informed on the risks of false results.

Research funding is hard to come by if you want to study something politically incorrect like vaping as tobacco harm reduction or the potential harms of gender reassignment treatment.

Modern medicine has many achievements. However, it is guilty of over reach and over promising.  Spinning results to make treatments look better than they are is akin to selling snake oil. Next time you hear crowing about “evidence”, be questioning.