This Week in Scientific Fraud at Harvard

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61

Well that is why the experience of a good clinical doctor matters. Because s/he needs to have far more experience than just the medical degree.

I asked my dad how old would you want your doctor to be just two weeks ago. His response around 60 years old. After medical school they have little experience. Some doctors are excellent at age 50 but usually at age 60 a doctor truly has a great deal of experience to bring to the job.

That is relevant to this discussion. Just reading is not seeing people with the diseases and prescribing treatment. Studying and treating are night and day.

The 10% or so that is correct are major successes.

If we have a conversation about xzy that say @btresist has hypothetically and someone pipes up to say, “oh try ABC supplemental. I read you can solve that in three weeks”. That is not the experience necessarily of a doctor. There is a reason for being a licensed doctor.

Wrong and fraud are two different things. People make mistakes. People are wrong. People become outdated in their research.

The baby is being thrown out with the bathwater because the laymen know a lot is wrong with medicine. The laymen do not know specifically what is wrong with medicine. The doctors do.

After all we all keep dying. It does not completely work. That does not imply malpractice.

62

True…but irrelevant. The answer to a different question, in fact.

So, if, as you contend, so much research is wrong or even fraudulent, how come you as an individual place your own personal confidence in this paper as an illustration of your opinion.

You’ve mentioned upstream that the anti vaxxers quote the wrong science (FWIW, they quote and misquote whatever they wish in order to validate their claims), right? This is a publication that implies an unforseen set of side effects that folk might have a right to be concerned about, I’d say.

Another question…did this particular publication jump out at you as you were reviewing all available literature methodically, or did you type a specific question into your search engine in a way that introduces a preliminary bias?

Did you check to see if the work was undertaken at an academic institute or no? Not a deal breaker either way, but there is usually a bit more quality assurance when an institution has an army of other researchers, statisticians etc all to eager to ask the important and all too frequently lacking questions like “what did you do wrong” or “is there an alternative explanation” at the pre-submission stage.

Then, another…and increasing important question when it comes to credibility…where was it published. Were you curious about Cureus? A journal I’d never heard of before. There are so many nowadays, I couldn’t name every high impact journal even in my own field. What I’m actually looking for isn’t so much whether it’s published in the publication leaders, Science, Nature, NEJM etc…but whether it’s what I’d call “legit” or is it one of the increasingly problematic predatory, pay to publish, editorial review-free, sites that are cropping up like a dose of The Pox. I saved you the trouble of scurrying back to do this rudimentary bit of checking…

Cureus - Wikipedia.

Full disclosure, I do not recall ever reading about these sources in Trish Greenhalgh’s excellent little book as I don’t think they existed back then. I bet the fifth edition contains a good bit about them

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63

What does this have to do with the quality of medical papers? The issue isn’t what makes a good doctor. The issue is whether we can trust published medical research.

In about 2020, the first mRNA-based vaccines against Covid were introduced. The mRNA tech had never been used in vaccines before so the only information about the safety of these vaccines at the time came from peer-reviewed research papers. Imagine you are a doctor who believes that most published medical papers are wrong as you have stated. A worried patient asks if the mRNA vaccines are safe.

How would you answer?

There are anecdotes and there are data. The data show that if you want to live longer, your odds are better with a younger doctor.

We looked at nationally representative data on Medicare patients hospitalized between 2011 and 2014 with a general medical condition and treated by a hospitalist physician, a general internist who specializes in the care of hospitalized patients. Our final sample consisted of approximately 700,000 hospitalizations treated by 19,000 hospitalists in 3,000 hospitals across the United States.

We found that patients treated by older physicians experienced statistically significantly higher mortality rates than patients cared for by younger physicians. Thirty-day patient mortality rates were 10.8% for physicians under 40, 11.1% for those age 40–49, 11.3% for those age 50–59, and 12.1% for physicians age 60 or older. Do Doctors Get Worse as They Get Older?.

Another study with a different data set showed much the same.

According to findings in the American Journal of Medicine, patients whose doctors had practiced for at least 20 years stayed longer in the hospital and were more likely to die compared to those whose doctors got their medical license in the past five years. The results highlight "issues that we have as a medical profession in keeping up to date" with the latest medical knowledge, said Dr. Niteesh Choudhry of Harvard Medical School, who was not involved in the new study. It is “a quality of care problem that has been recognized for five to 10 years,” he told Reuters Health. https://www.reuters.com/article/idUSTRE76E62T/

Medicine is progressing rapidly so it is often difficult to keep up to date on the latest medical knowledge. This is particularly true if one believes most medical papers are wrong.

IMO, what matters most is the size of the practice. Older doctors treating lots of patients will probably be as current with the medical literature as the young whippersnappers. However, statistically speaking, the odds seem to be better with younger doctors being more knowledgeable about the latest methods.

https://www.bmj.com/content/357/bmj.j1797
https://www.acpjournals.org/doi/10.7326/0003-4819-142-4-200502150-00008

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64

I think you might be confused again about scientific vs general/lay terminology.

In scientific research terms a “collaborative effort” doesn’t mean the same as when an 8th grade science teacher is referring to plain ole copying in a euphemistic way. Like, say, checking your results against your mate’s in the Boyle’s Law experiment.

A collaborative effort means utilizing the different skill sets, available technology and available techniques that one lone researcher isn’t likely to posses or have time to utilize if they do. One paper that I was a co author on years ago (investigating the levels of nitric oxide produced in periodontal disease), I collected the saliva samples for testing by RIA…because I was the only person in the group licensed and with the relevant patient base to do so. I didn’t perform the RIA because it’s specialized equipment not commonly found in a clinical dental setting…and I lacked that skill set. I didn’t write the IRB and patient consent forms because I didn’t actually know (or invest the time to learn) the acceptable format. etc.

As you can see, even elegantly simple studies can be quite complicated to perform.

65

If we only had “practical medicine” and no research, leeches would still be cutting edge technology.

Research changes the “real world”. Antibiotics as just one example created a new medical environment.

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66

Well, before someone lurches in with a Gish Gallop of links to use of leeches in modern medicine, I’d cite the world of psychiatric care to make it a bit more relevant…and, say, the continued use of frontal lobotomy as standard-of-care if personal experience and practical medicine only are used to power decision making.

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You are totally out of touch on the topic.

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snippet

So, among doctors who saw lots of patients, older doctors seemed to deliver the same quality of care as their younger colleagues.

snippet

What These Findings Mean

We were not able to assess exactly why older physicians had worse patient outcomes. One possible explanation could be that it becomes more difficult to keep up with scientific and technological advancement over time.

My comment you can not see clickbait versus bad research processes.

To make this stupider it is reported in the Harvard Business Review.

69

Occasionally used to stop seizures.

Leeches were the best of science in their day. Theory. I am not the one saying anything I read in a research report is correct. You are. You are the believer.

Research only remains valid if the practical doctors report ongoing success. There is no separation between the doctors and scientists. Remember scientific theory is predicated on hypotheses, theories, and conclusions being stricken as invalid or supported valid.

70

Nope. I’ve spent a great deal of time and effort being trained to critically evaluate scientific papers in the life sciences. It’s an important part of my career. It is a large part of what PhDs/MDs do. I am able to determine on my own whether a research study is “correct”.

As far as I can tell, you don’t have the training to critically evaluate medical research, yet you have the temerity to claim that most medical research is wrong. Your belief seems not to be based on personal expertise but rather on faith in what someone else told you. In fairness, you are the believer.

Even though it is irrelevant to the assessment of medical research I am glad you brought up this claim that doctors are best in their 60s. It got to look at the medical literature and discover that patients with younger doctors tend to have better medical outcomes. My doc is in his 40s so I seem to be optimizing my health care, at least from a statistical POV. To sum up the data I have found.

Way back in 2005, a meta-analysis concluded that:

Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions. https://www.acpjournals.org/doi/10.7326/0003-4819-142-4-200502150-00008

At the end of this paper are a serious of comments from other doctors with scathing criticism. Fun to read and not surprising as this was an obvious challenge to a lot of older doctors.

These findings were supported by another study from a different set of authors that was linked earlier.

Our findings suggest that within the same hospital, patients treated by physicians aged <40 have 0.85 times the odds of dying (1.00/1.17) or an 11% lower probability of dying (10.8/12.1), compared with patients cared for by physicians aged ≥60 (table 2). This difference in mortality is comparable with the impact of statins for the primary prevention of cardiovascular mortality on all cause mortality (odds ratio of 0.86) or the impact of β blockers on mortality among patients with myocardial infarction (incidence rate ratio of 0.86), indicating that our observed difference in mortality is not only statistically significant but arguably clinically significant. https://www.bmj.com/content/357/bmj.j1797

That’s pretty remarkable in my mind. The age of your doctor has the same health impact as β blockers or statins!

Another study found that:

The study findings show that younger health professionals more consistently practice daily competencies than their older counterparts, especially in the use of evidence-based practice, informatics, and working in interdisciplinary teams. https://journals.sagepub.com/doi/full/10.1177/23779608211029067#bibr9-23779608211029067

And another study of patients with Acute Myocardial Infarction found that patients mortality rate increase 0.5% for every year since their cardiologist graduated from med school. https://journals.lww.com/academicmedicine/fulltext/2000/12000/certification_and_specialization__do_they_matter.16.aspx

It appears that being current on recent advances in medical research/practice positively impacts patient care. Younger doctors have an advantage over older ones in this area.

I have a vague recollection this topic was brought before. My apologies if it is repetitive.

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71

Nonsense you see none of the later results when things do not work at all in the doctor’s office. Your upfront information is often useless.

You can not even hold both ideas in your head. You see very detailed research. It does not stand up to time. Those two ideas are beyond you. That is why I am calling you a believer.

You are bringing up statistics as if those are facts. That is a failing in itself because you do not know medicine. Medicine is experiential. Statistics are often fabrications.

https://www.tandfonline.com/doi/abs/10.1080/13607860802459831

72

So…is this particular study one of the few that you’re confident does not contain fabricated statistics? Or an example of one that does…and you’re going to point it out?

Again, what is your own scientific background that leads you to these odd ideas about research and the Scientific Method? You state them with such dogmatic assurance and succeed in getting it wrong every time (like a good many other topics, I suspect) that I can only assume it’s minimal…or else you’d be a bit more circumspect

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73

I never claimed it was my background.

I am an observer in a medical family from the cradle. The doctors dismiss studies endlessly. Just posting someone has a Ph.D and has training in another field to read this means nothing to the application. It is totally meaningless to have only read these things. He is very confused. Most of it does not apply later. Much of it is wrong.

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It is his experience. You have no experience.

Your Ph.D was mentioned earlier. It is not in medicine. You like reading this stuff. You are not trained even if you like to pretend you are.

75

Yet, you’re so belligerent in your accusations that others are ignorant when challenged on a topic where you’re hopelessly in the wrong (like, say, dietary protein and carbohydrate producing serum glucose equally quickly) that it looks mightily as if you think it is somewhere in your background. Simply by virtue of “coming from a medical family”.

If, in fact, you’ve received minimal exposure to critical thinking and fundamental understanding of the Scientific Method plus
the role of research studies in the scientific archive, that’s a failure in your education…both formal and whatever you’ve picked up from those who raised you. It’s left you unable to think for yourself on, at least, subjects like this and, instead, to merely parrot what you’ve been told…or to hunt and peck on Google until you glom onto a study that appears to validate your opinion

If all the physicians in your family have made a practice of studiously avoiding any and every study and dismissing then for whatever reason, that’s not practising thinking medicine. Quite the reverse…it’s outright scientific denialism. Whilst they may imagine that they’re only insulating themselves from prescribing harmful drugs, they’re also missing the relevant evidence for the beneficial ones too…along with the insight that their own favourite treatments or procedures (based on the evidence of their own eyes) are at best useless.

The thing to remember…or be aware of if you didn’t know in the first place…not every scientific investigation, even in the biomedical field, is intended to inform decision making in clinical practice. That might appear to be the case if your only exposure to studies is via Science By Press Release and the stuff that drifts across your radar screen through media outlets, but it’s not. Rather, I suspect the majority are like the nitric oxide/periodontal disease study I was involved with back in the 1990s…to see if levels in saliva correlated with degree of disease process in another yet another inflammatory condition (there was nothing in the literature on it at the time so, yes…a novel concept with the early hypothesis testing suggesting it did) Adding another tiny jigsaw puzzle piece to Life’s Big Picture rather than writing a route map for future treatment.

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76

I have misgivings pursuing this because you seem to be taking everything very emotionally and personally. However, you bring up two points I think are important.

First, Richard Smith’s personal experience is just anecdotal evidence. It is a justification for an opinion, not for a science-based conclusion. In comparison, experience recorded systematically with the appropriate controls and statistical support can be considered science appropriate evidence.

For example, my eating a certain mushroom and feeling sick is an anecdote. My recollection that others who tried that mushroom often felt sick is still anecdotal, and as such not all that convincing. A doctor treating a couple of people who ate the mushroom and had stomach cramps is also just anecdotal. Contrast that with a randomized survey of 100 people who ate the mushroom with 85% feeling sick and statistical analysis showing that this result is significantly different from a control group who ate a harmless shitake mushroom. Now we are approaching scientific credibility.

Second, you don’t seem to understand the concept of “critical reasoning”. As a graduate student I had to lead countless journal clubs where one had to present a paper with the audience asking questions about the appropriateness of the methodology, whether the sample size was large enough, was the statistical analysis sufficient, did the data justify the conclusions, etc etc. We were taught in great detail how to dissect and assess scientific research. A Ph.D. is not simply additional knowledge, it is also a training of the mind on how to approach a problem. It is like a mental martial art. You can watch a lot of Karate self-teaching videos on Youtube. But that isn’t nearly the same as having years of practice with expert mentors.

Finally, I am not an MD. But I am a molecular/population geneticist. I’ve isolated RNA, I’ve artificially synthesized RNA, I’ve generate genetically modified organisms, and I’ve done detailed phenomenological studies to determine the effects of the genetic modification. Turns out that an increasing amount of medical research involve molecular/population genetics and genetic modification. I think I am in better position to evaluate, as one example, studies on the safety of RNA-based vaccines than the great majority of those MDs doing primarily clinical work who may have never even sequenced a gene, let alone try to assess the impact of specific mutations within the gene. I don’t say this to brag, but to simply point out that in this particular area you have no idea what you are talking about.

I’ve read a fair amount of scientific papers and quite a few papers from medical journals. One can often find things one would have done differently but the claim that most of these papers are wrong is IMO nonsense. I have yet to see any evidence in support of that assertion.

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77

Out of curiosity, did this study take into account the possibility that older doctors were assigned sicker patients because of their experience? My guess would be that they did, as it’s an obvious enough possibility that even I as a lay person could think of it. But it would be nice to either confirm my guess or to learn what else they did to deal with the relative “sickness” of the patients.

—Peter

78

It is a good question and is mostly relevant to the BMJ study that tracked 30 day mortality rates. The other studies mostly measured different aspects of physician skill and knowledge rather than patient outcomes.

The answer for the BMJ study is partially. Here is what the authors’ state specific to your question:

Our study has several limitations. First, our findings would be confounded if older physicians, on average, treat patients at higher risk of 30 day mortality because of factors unmeasured by our analysis. We specifically chose our within hospital study design to deal with this concern, hypothesizing that patients are essentially randomized to hospitalist physicians of various ages within the same hospital, an assumption supported by the largely similar demographic and clinical characteristics across patients that older and younger physicians treat.

In short, they chose a method that they believe would reduce the likelihood of this bias, but they did not control for it directly. If you look at Table 1 one sees that the number of comorbidities is equal in the patients populations of each physician age group, however there were some differences in specific diseases.

The authors recognize the limitations of the study and so were circumspect in their conclusions. They state the correspondence between physician age and higher mortality rates and suggest that one likely explanation is that younger doctors are more knowledgeable of the newest medical methodologies but also note other factors are possible.

79

Thanks for that.

It would be interesting to see a follow up on this. I know that one reason for the residency requirement for MDs is to gain experience with patients, as that experience is necessary. One would hope that at the end of residency, the new MD has sufficient experience to be competent, but probably doesn’t have enough to be expert in their field. So it seems there should be some continuing ramp up in patient outcomes as the doctor gains more experience and improves from competent to expert.

As a patient, that might make me biased toward doctors that aren’t the newest in their field, but perhaps to those who are a few years out of residency.

As I age, I am noticing that I have to work a bit harder to keep up with the latest changes in my particular area. I need more repetitions of new topics to become comfortable with them. In my 30s, I’d retain information on just one or two readings. Now at 60+ I need 3 or 4 to get that same retention.

This is making me more cognizant of what it takes to maintain expertise in any particular field.

–Peter

80

I am not wrong at all. You are now misleading everyone here.

The research is often wrong.

You still have not refuted his experience.

Every doctor in my family circles from my father’s generation to my BIL’s generation would agree with Richard Smith. But you are special? Hardly.

The character assassination was where you come from. You can dish it out but you can not take it.