The Case for Evidence-Based Medicine in Clinical Reporting:   Should We Replace Our Degrees with an Asterisk?


Robert M. Kershner, MD, MS, FACS

Clinical Professor, University of Utah School of Medicine, Moran Eye Center, Salt Lake City, Utah

Ik Ho Visiting Professor of Ophthalmology, Chinese University of Hong Kong

Director Emeritus of Cataract and Refractive Surgery and Anterior Segment Fellowship Program

Eye Laser Center-Tucson, Arizona

Consultant Specialist-Teaching, Research, and Information Technology

Eye Laser Consulting

Boston, Massachusetts   USA



           The role of the scientist is to share knowledge with others. Science , as derived from the Latin root scire “to know”, is what we, as physicians, are all about. We are supposed to have knowledge and we are supposed to share it honestly with the public. In the 70s, I trained in graduate school as a scientist, obtained a master's degree, worked on a doctorate, and became a dyed in the wool academic scientist.   Sadly, the trend today towards academic research is changing. According to the 2002 Survey of Earned Doctorates from the National Science Foundation, the number of research doctorates has been steadily decreasing over the past five years, from a peak in 1998 to just under 40,000 degrees from 413 universities in 2002. The number of science and engineering doctorates awarded were just over 25,000, and of those, 45% in the physical sciences and 61% in engineering, went to non U.S. citizens from China, South Korea, India and Taiwan. America is becoming illiterate when it comes to scientific research.

           My link to the scientific world was hard to shake when I entered clinical medicine with an MD degree. I still viewed everything with a healthy dose of skepticism born from years of scientific inquiry and I still read everything with a critical eye, even the morning paper. I find it very difficult to accept conclusions based on the face value of what I hear at clinical meetings and what I read in our non-peer reviewed publications.   Especially when there is a commercial bias to the reporting. We are inundated with information from drug companies and medical/surgical suppliers that tout the latest and greatest new advance. We as physicians, need to remember that first we must be good scientists. Not everything new, is better.

           As a well-published author, I know all too well the frustration of trying to get a hard-earned work before an editor and past a cadre of reviewers who felt obligated to prevent a scientific paper from escaping its dissection. A scientific paper must undergo rigorous review before it ever sees the light of a galley proof printing press. The printed record of that medical research should be credible, lucid and precise. The downside, is that the process creates a significant delay before the written work is seen by the discerning eyes of a reader.

           The need for rapid dissemination of medical information is more acute today than it has ever been.   When I was in graduate school, a new publication addressed these concerns by taking papers submitted from researchers, reviewing them quickly and then copying them directly into the publication. It wasn't a glossy journal, looking more like a graduate student's notebook, but it accomplished what it needed to do. The publication eliminated the delay in getting the scientific information out.

           In the age of cable news, the internet, and on-line publications, the ability to rapidly disseminate clinical studies has achieved a speed never before seen. Many of the big drug companies market the results of these studies directly to the patient rather than through the doctor. The evening news saturates the viewer with the latest cure for heartburn, leaking bladder and impotence.   What doctor hasn't been asked for a prescription for “the purple pill” when neither the patient nor the doctor even know what it is for?   Information alone, without knowledge, is potentially dangerous. The need to disseminate information on new drugs and new medical devices, has to be tempered with the knowledge from the right person to use it wisely.

           I trained in general surgery before I entered the field of ophthalmology. In most surgical specialties it is the academic centers where clinical studies are conducted and medical breakthroughs are charted. The two and half decades during which I have practiced ophthalmology, experienced a very productive growth in scientific knowledge and clinical technique. Most of this occurred in private practices outside the jurisdiction of the academic environment.

           With the tremendous growth in medical knowledge has come the burden to pass along these techniques and breakthroughs to our colleagues and the public. As practitioners, we have become impatient.   We want to know what is the latest and the greatest, and we never want to miss out on the next great thing. We faithfully attend meetings, read every glossy publication that comes our way, and even cruise the internet in search of continuing medical education. We have learned to accept everything on face value in the name of speed.

           I admit I read many of the colorful publications that come my way, especially when they have fancy graphics and color photographs of clinical procedures.   We all want to learn. We all need to satisfy an intellectual curiosity to see what others are doing. But we also have an obligation to know the truth.  

           Recently I attended a large regional medical conference where I listened intently as many a practitioner espoused their “amazing” results. I read several of the non-peer-reviewed publications that disquise themselves as “journals” discussing new devices and procedures. Predictably, the claims made met my critical eye. What ever happened to evidence-based clinical reporting? In their exuberance to share their newest and greatest technique, some practitioners may have glossed over what actually didn't work. In our graduate studies, negative results were often more valuable than the positive ones. We need to know what is bad about something as well as what is good.   In medicine, we seem to want to focus on the good.

           Are we experiencing a wave of intellectual dishonesty when a physician gets up to the podium and speaks about a manufacturer's product as if it was his own while blanketed in the comforting knowledge that an asterisk after her name signifying the “paid consultant” status of the report absolves the speaker of all guilt? Or have we learned to ignore the paid endorsements for so much of what we read and hear today that the information now is no longer tainted just because it is paid for?

           In all fairness, many medical doctors can't be faulted for not appreciating the importance of evidence-based medical reporting, when, after all, their only experience in the process may have been a monthly journal club during residency training.   We individually and collectively need to ask ourselves as well as our peers, the hard questions. Is there fact behind the fiction, can the results be independently replicated, and has enough data been objectively collected to add meaning to the results that are being reported?   Until, we do, we all should put asterisks after our name instead of our degrees.