Medical Mythology: Etiology, Prevention and Treatment Document Transcript
Medical Mythology: Its Etiology, Prevention andTreatmentBy Dr. Thomas F Heston , Dr. Marc GosselinCorresponding Author Dr. Thomas F HestonInternet Medical Association, 848 N Rainbow Blvd #1289 - United States of AmericaSubmitting Author Dr. Thomas F HestonKeywords: Mythology, Medicine, Evidence Based Medicine, Folklore, PsychologyHow to cite the article: Heston T, Gosselin M. Medical Mythology: Its Etiology, Prevention AndTreatment . WebmedCentral GENERAL MEDICINE 2010;1(9):WMC00744Link to previous version of the article: NoneSubmitted on: 25 Sep 2010 08:40:19 AM GMTPublished on: 25 Sep 2010 09:27:29 AM GMTAbstractMyths are widely held beliefs that are false or of unverifiable existence. In medicine, they are not justunproven theories or mistaken conclusions, rather, they are fictitious ideas that weave their waythroughout the profession. In order to prevent and treat medical myths, they need to be recognized as adisease that is harmful to patient care. Using established principles of medicine, the myths then can bemedically managed and a cure attempted. To accomplish this, the myths need to be understood in termsof their etiology and pathopsychology. A firm understanding of biostatistics and the principles ofevidence based medicine is essential to the prevention, management, and cure of medical myths.Medical MythologyThroughout the history of medicine, whenever new ideas are found, we have traditionally gone back tomythology. Much of our medical terminology, anatomy and disease names have origins frommythology, such as Achilles, Atlas, Narcissus and Panic (from the God Pan). This may be secondary tomans discomfort of change, resulting in an immobilization of newer ideas by offering a feeling ofsecurity in tradition (1).In medicine, a myth is a widely held belief that is false or of unverifiable existence (2). it is more thanjust an unproven theory or mistaken conclusion. Rather, medical myths are fictitious ideas that weavetheir way through the group psyche of our profession (3). In order to both prevent and treat thesemyths, we need to recognize them as a disease, and use our medical skills to treat and prevent them.First, we need to thoroughly understand medical mythology and its etiology. With this understanding,we can then design ways to systematically prevent and eradicate the myths. In this article, we will
define medical myths, explore their etiology, and finally, propose methods to eradicate old myths andprevent new ones.Medical myths are irrelevant standards of care that do not help a patient, and occasionally, actuallycause harm. They become widely disseminated throughout the profession during medical trainingthrough lectures, opinion articles, and textbooks (4). Oral transmission of the myth by other students isperhaps the most powerful vector, however, outside of academic institutions, myths continue to thrivewhen consultants repeat the fallacies.An example of a medical myth was the widespread use of hormone replacement therapy (HRT) inwomen for the primary prevention of coronary artery disease (5). This practice started in the late 1980sand flourished in the 1990s. It quickly became the standard of care. HRT was metaphorically viewed asan elixir of life, and those who did not prescribe HRT were considered uninformed or bad doctors.The story of HRT for the primary prevention of coronary artery disease highlights a couple ofetiologies that are common in the development of a medical myth. First of all, there was solidphysiological evidence suggesting a cardioprotective effect of HRT (6, 7). Secondly, there weresignificant biases in the research, e.g. one major study only looked at caucasians (8), and another onlymembers of a regional health maintenance organization (9). The inappropriate extrapolation of suchphysiologic evidence and biased research to clinical medicine helped feed and nurture the myth of HRTfor primary cardiac prevention.Ultimately, a large, randomized clinical trial found that HRT was not indicated for the primaryprevention of coronary artery disease, or any other chronic disease for that matter (10). Subsequentrandomized clinical trials have subsequently refuted the conclusions from the earlier, biasedobservational studies that HRT was effective as a primary cardioprotective measure. These new clinicaltrials reached a different conclusion partly due to the fact that they included an evaluation ofconfounding variables not examined in the previous studies.For example, while earlier observational studies concluded there was a positive effect of HRT oncoronary artery disease, a subsequent randomized clinical trial found that HRT actually increased therisk of stroke and overall cardiovascular disease (11). Furthermore, when the total mortality wasevaluated, it was determined that the overall risks of HRT clearly outweighed any possible benefit (12).Such medical myths are dangerous not only because of their inherent falseness (resulting in suboptimalmedical care), but also because they are highly resilient and resistant to change. Myths becomeespecially powerful when they involve issues of life and death, because this emotional componenthelps turn a myth into a widely distributed meme (13). These memes, which circulate units of culturalinformation much in the same way genes pass on biological information (14), can become pathologicalwhen they propagate false ideas. The memes that transfer false ideas throughout our profession can actlike thought viruses (15). If we are to provide the best possible care for our patients, we need to attackthese thought viruses head on. We start the process by understanding the etiology of a medical myth.At its foundation, the etiology of a myth is an incorrect conclusion drawn from good data, or a correctconclusion drawn from bad data. This faulty thinking results in the adoption of a falsehood as truth.One example is when we adopt a hypothesis as true, simply because it makes logical, pathophysiologicsense. Another example is when we blindly accept the teachings of a medical expert without examiningthe basis of their opinion, or the adoption of a common practice which has not been objectivelyevaluated (16). A third example is when a poor understanding of biostatistics leads to themisinterpretation of medical research . Putting logic ahead of the scientific method, excessively relyingupon expert opinion, and an incomplete understanding of biostatistics all contribute to the etiology of amedical myth. In order to eradicate and prevent myths, we need to address all of these core etiologies.
The eradication of a medical myth needs to focus upon the profession as a whole. Because a falsemedical theory only grows into a myth when it becomes widely adopted, its cure only comes aboutwhen the majority reject the false idea and replace it with a truth. In order to bring this about, the focusis upon the small units, the memes, of a larger myth. As these memes evolve, we come closer to thetruth and the myth gradually dies off.This eradication of mythical memes in medicine is already solidly underway. Perhaps the best exampleof this is the Cochrane Collaboration, which has instituted a rigorous and systemic approach to theevaluation of the medical literature (17). Furthermore, many medical organizations are doing awaywith blanket expert opinion consensus statements. Instead, guidelines are presented with a strength ofevidence score, which helps acknowledge the deficiencies and gaps in our knowledge (18).The Internet has also served to treat medical myths by allowing a faster and easier way fornonacademic clinicians to peer review journal articles. A good example of this process are journalswhich allow the online community to post Rapid Responses to their articles (19). Typically, theypublish just about anything that isnt libellous or doesnt breach patient confidentiality, and based on thelarge number of contributors, the response from the online community has been overwhelminglypositive (20). Rapid responders, as they are called, note significant benefits, including the aspects ofonline peer review (21) and greater attention to the original article (22). One rapid responder evensuggested posting research articles anonymously on the journal website before publication, toincorporate an online peer review in addition to the traditional expert peer review (23).Treating established medical myths, however, will never be fully effective unless strong measures aretaken to prevent myths in the first place. Preventing bad data from getting into the medical literature isa primary goal. One way to do this is to minimize the link between the pharmaceutical industry andmedical researchers (24). Having authors state any conflicts of interest at the end of the article is notsufficient, because it is now clear that capitalistic interests and monetary profit can affect what researchis published, and how it is presented. In addition to conflict of interest disclosures by authors, journaleditors and reviewers also need to disclose their conflicts, because of their large impact upon whatultimately gets published (25). Journals also need a quality control system in place to ensure againststatistical abuse, which is very easily accomplished (26), especially when conflicts of interest come intoplay.The prevention of a myth also requires us to correctly interpret good data. Unfortunately, the medicalprofession continues to be plagued by innumeracy. For example, internal medicine residents as a groupcontinue to have a worrisome knowledge deficit when it comes to biostatistics (27). This is not a newfinding, but rather a long-standing problem that remains unaddressed (28, 29, 30). One study of Danishdoctors even concluded that the statistical knowledge of most doctors is so limited that they cannot beexpected to draw the right conclusions from those statistical analysises which are found in papers inmedical journals (31). While innumeracy pervades society as a whole (32), we must not allow it to berampant in the medical community. All medical professionals must have at least have a basicunderstanding of how to interpret biostatistics and understand research methodology. The failure ofmedical schools and continuing medical education programs in teaching statistics needs to be corrected.One suggestion to help the situation is to require statistical training as a prerequisite to medical school(33).Although measures are currently underway to treat and prevent medical myths, there continues to be aproblem. Medical mythology, the disease, continues to thrive. The implementation of evidence basedmedicine is a positive step, by reducing our tendency to rely solely on opinions and biased studiesrather than observation and the scientific method. Having practice guidelines incorporate weight ofevidence scores has also helped, by decreasing the negative effects of expert opinion. However, thereremains a suboptimal understanding of biostatistics and research methodology by medical
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