The 4 stages of evidence enlightenment

The natural evolution from being unaware, to embracing uncertainty

I have a passion (obsession?) for clinical research and its implementation in practice, but it was certainly not always like this! It’s been a journey from when I started medical school to where I am now, preparing to complete my PhD in infection, inflammation and immunity.

Looking back, I can identify a few stages of this journey which I also recognise among my colleagues. I was discussing this with my brother (a critical care paramedic and excellent clinical academic). He thought it was quite interesting, so I thought I would share it here.

Let me know your thoughts, and see if you recognise where you (or your colleagues/friends) are along the way. If you’re not a clinician, hopefully you’ll still find it interesting!

Stage 1 - Unaware

This is the blissful stage where most of us start out. It is a product of the way clinical education is usually taught:

X symptoms = Y condition = Z treatment

There is usually little or discussion about the primary research underlying these diagnosis to treatment models or the uncertainty in them. Initially you are so busy just trying to learn the volume of material to even question this, and it seems unnecessary.

Many people never leave this stage. It leaves you with a very understandable attitude of , “Research is boring and for academics, I am a clinician and it is not relevant to me”. But this could not be further from the truth!

Stage 2 - Aware, excited and naïve

Some practitioners who are a more curious or have the benefit of good teachers/opportunities may stumble their way into the primary literature and love it! Your eyes become open to the fact that everything we “know” about the body or medicine has to be based on some research done somewhere, and now every study you read helps you to “know” something new.

The common danger with this stage is too much trust in the published literature. If a study has been done, and the authors report the findings, that is “The Science” on the topic. “New research study finds X”, means that X is true. Without an eye for critical appraisal, the frequent shortcomings or biases inherent in a lot of clinical research go unnoticed.

Stage 3 - The Nihilist

Full of enthusiasm, our research adventurer gets stuck into learning critical appraisal skills. Bias, confounding, statistical interpretation, all good stuff. But oh dear. Now their eyes are open. What they are seeing is an absolute horror show.

Most clinical research is WRONG. Everything is irreparably BIASED. There are NULL results everywhere.

We know NOTHING and absolutely NOTHING works!

We should all give up. Medicine is a ridiculous waste. What is the point. Stop everything!

Sadly, the state of the medical literature is very poor. There are numerous reasons for this, including bad teaching and terrible incentives for junior students and clinicians to church out very low quality projects to buffer their CVs. This led to Doug Altman, one of the most important individuals in the field of Evidence Based Medicine, to produce the famous quote, “We need less research, better research, and research done for the right reasons”.

So dire is the situation that many may never move on from this phase. But all is not lost!

Stage 4 - The Pragmatist

Among the ocean of research waste swim pieces of beauty. There is some truly excellent research being produced, and its influence can be great. Even among the sea of seemingly poor quality publications there are often snippets and gems to be found which can enhance our knowledge. Rarely is a study so completely wasteful that we can glean nothing from it what-so-ever.

Here we embrace uncertainty. We can rarely ever be 100% certain that anything we are implementing in practice is truly a net positive, but we don’t need to be. We just need to be sure enough that the costs and risks associated with the intervention are outweighed enough by the probable benefit to be high value.

Realistically, we need high quality clinical trials to be able to confidently introduce pharmaceutical products into practice. We could do with many more of them for many more interventions. There are other questions which are not amendable to RCTs, and for these will will just have to make our best possible judgement with the available evidence at the time. Sometimes this will mean doing nothing. Somethings it will mean cautiously introducing things, and constantly re-evaluating.

Every inch we move forward is an inch closer than we were before. Eventually we may finally end up somewhere where really good stuff happens!

Most importantly, we need to use our knowledge to be champions for increasing the quality of research and research education.

Summary

To get to a stage of becoming a well rounded evidence based practitioner means getting through the dangerous stages of blind trust in research, and complete nihilism instigated by the poor state of the published literature. It is not always a unidirectional journey either - I often catch myself re-descending into nihilism (especially after some new dodgy study ends up all over the news and social media with highly questionable results - a frequent occurrence).

These dangers can be minimised by improving the state of education of health practitioners around the scientific backbone to what we do in practice. It is the most important part of what we do, but it is no panacea. We need to approach the literature with scepticism without descending into nihilism. Acknowledging the huge amount of uncertainty that underlies our fields helps us to approach problems with more humility, and I like to think helps us engage more effectively in shared decision making with our patients.

Do you see yourselves or others on this journey?