“A scar on the moral body of science” is how Dr. Richard Horton of the top-flight medical journal “The Lancet” described a recent high-profile case of medical fraud. The Wall Street Journals write up is worth a read: online.wsj.com. In my view, the Lancet did not accept adequate responsibility for its sloppy editorial supervision of this story.

It was endlessly drilled into us in medical school that when reviewing the literature or hearing a lecture, to always ask “show me the data?” We were also given a pretty good education in stats, especially as they related to the interpretation of the clinical trials that are the foundation upon which medical treatments are based. As a result, docs are among the most skeptical crowd you could meet. But no matter how much one knows or tries, especially for the busy practitioner, its hard to keep up with the science, and one will be fooled. Pity the lay public, which rightfully expects their provider to be giving them scientifically based advice. What is a patient to do?

First of all, realize that a LOT of the advice you get is NOT based on irrefutable medical evidence. It cannot be. There are not enough research dollars nor facilities to answer every single clinical question with the rigor we'd like. The hope and the goal is that the new, big and dangerous treatments are based on good science. You are unlikely to find a good trial of heat vs cold in the treatment of aching feet. Its OK to wing in now and then and “see what works best”. Its not called “practicing medicine” for nothing. But you should expect good data on a breakthrough/new medication and ask hard questions about comparative effectiveness, side-effects, alternatives etc.

Recognize that there is a difference between legitimate debate and unavoidable mistakes in interpretation, and overt fraud. The former is common and natural and expected in the glacial march of science. Conclusions will change over time, and as a result, so will therapies. This decades conventional wisdom will be laughed at in future.

Outright research fraud is still relatively rare, but may be on the rise. While I'd not suggest that the medical literature has fallen to the level of the tabloids, both the lay public and the average practitioner
must be on the alert and think critically.

Why does this fraud happen? Turns out the geek with the pocket protector has the same human flaws as the rest of us. Her research funding and career may hinge on the big discovery. Her supervising director may be inattentive or similarly motivated. The prestigious medical journal may have short-staffed its editorial panel, or be looking to “scoop” the competition with a breakout story. The pharmaceutical representative who is “detailing” the new product is not incented to dwell on the negatives or unknowns of this promising new drug. And so it goes.

It's very hard to mop up once the mistaken interpretation or fraud has gained momentum among treating providers in the clinic. Patterns become established, patients become convinced that a certain remedy works, and sometimes the evidence to the contrary, the “retractions” etc, are not given sufficient attention.

So what is the patient to do with a new treatment suggestion? Same thing you'd do when you shop for a car. Ask questions. Question motivations. Follow the money. Develop your critical thinking skills, and pay particular attention to new stuff. We'll put some of this advice to the test in a future piece on “Complementary and Alternative Medicine”.

Stan Seagraves M.D., an internist who has practiced in Missoula for over 20 years. He is currently practicing hospital medicine at St. Patrick Hospital, and is medical director of their hospitalist program.

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