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Editor's Notes |
A little more than a decade ago, I offended an equipment manufacturer in one of these notes because I observed that the company's promotion department seemed to have outpaced its research department. I bemoaned the fact that instead of seeing scientifically credible reports in peer-reviewed literature, we were being assaulted by television "news" stories with outrageous promises and claims more grandiose than those you would hear even from the most shameless of snake-oil salesmen.
In "Heralding of Breakthroughs" (January 1990), I wrote: "In the two days before this Editor's Note was written, reports on two television networks, NBC and CNN, related apparently wonderful news. According to these networks, it is now possible to detect, with absolute certainty, malingering in any patient who has low back pain. This breakthrough was, according to the reports, due to the development of technology in the form of new back-testing machines. Ironically, the two networks featured different machines, instruments of wholly different designs, instruments based on widely disparate theoretical models."
Here we are, a decade later, beginning a new millennium, and we still have no idea how to identify—with any certainty—patients who are malingering. We even continue to debate how to classify people with low back pain. The equipment has gone the way of the Dodo, and perhaps manufacturers and promoters have learned a lesson, but some recent evidence suggests that they have not.
The local news here in Chicago was recently infiltrated by what I would consider to be an infomercial in the middle of the evening news, extolling the virtue of microcurrent stimulation for pain. In a shameful example of irresponsibility, the local NBC affiliate gave an uncritical forum to those selling the devices. Testimonials came from device users and developers. There was no unbiased discussion, no consideration of whether there was any evidence.
This local affiliate is owned by the same NBC that a few years ago broadcast a Dateline exposé on the dubious use of electrical stimulation for weight loss and body shaping. As I watched that edition of Dateline, I was proud that a physical therapist researcher and clinician, Dr Lynn Snyder-Mackler, was able to discuss the devices. She brought honor to our profession as she critically evaluated the equipment and what it could and could not do. Nowadays, however, one can often watch infomercials on CNBC and MSNBC for the very same devices that are exposed on parent company NBC's Dateline. It seems to me that what's really being exposed—unwittingly—is not just the false claims of manufacturers, but the hypocrisy of a major American corporation that on one hand chooses to judge questionable devices harshly and on the other hand makes profits by advertising those questionable devices.
Perhaps I would be more indignant about the electrical stimulation charade if it was not for a new lightning rod that has attracted my attention. Once again I find that my studious use of the literature is of little value because medical breakthroughs are being trumpeted elsewhere.
One of the benefits (and I use that word with a bit of sarcasm) of a summer when airplanes seem to spend more time parking than flying is that you can get a lot of reading done. Sometimes you use up every readable paper you have, and you find yourself revisiting the in-flight magazines as often as a biblical scholar might refer to the Book of Genesis. In-flight magazines usually are mostly froth, but in this case, the froth had an ugly center.
There I was, wearing out my August edition of my United Airlines Hemispheres magazine, when something I had previously missed caught my eye. On page 120 there was a large box with a picture of man who was on a ladder and painting a building. At the top of the box, a headline announced, "Paralyzed From a Stroke for 4 Years, Recovered in 4 Months." The advertisement went on to claim that 80% of the patients seen at this clinic have a "major recovery" and that all of this had been documented in peer-reviewed publications. Wow! And, if that wasn't exciting enough, the very same technique that helped people with strokes also improved the abilities of people with brain injury, learning disabilities, and cerebral palsy. Double Wow!
The peer-reviewed publications turned out to be a Web posting maintained by the company. The names of the Editorial Board are listed on the site with some of their credentials. Of the 20 listed, 1 or 2 might qualify as reviewers for this Journal, but certainly none would be considered qualified to be an Editorial Board member. If the subject were not so serious, calling this publication "peer-reviewed" would be comical.
If you can help people with new treatments, you need to do your homework and do it right, and if you cannot do that, you are giving false promises—which is both cruel and professionally irresponsible. The behavior is intolerable, regardless of whether promoters are acting out of self-interest, financial or otherwise.
Within our profession, I have actually been told that my problem is that I fail to read the "unpublished literature." In addition to being an oxymoron, this is a very troubling statement. Worthy ideas will stand the test of peer review, which is the common currency of scientific thought. Shortcuts, as my daughters will tell you, are too often the excuse that we offer when we get lost or seek an easy path. My shortcuts are legendary, but at least they have consequences only for those in my car. The shortcuts of those who would bypass traditional means for ensuring the credibility of clinical approaches have far-reaching and often profoundly negative consequences. A decade ago when I reflected on the state of back care and the use of the lay media rather than peer review, I wrote the following, and it holds true today:
Confusion and contradiction in public by professionals often leads to cynicism among the public we are supposed to serve. This is in contrast to responsible and professional debate. We need not agree on all things, but we should agree on the forums and the mechanisms we use in questioning one another....New treatments and new evaluation tools should be evaluated through use of scientific methods, and reports on these breakthroughs deserve rigorous peer review. Purveyors of devices and promoters of treatments should adhere to responsible standards. New ideas and new devices should be evaluated by those with the tools and the expertise to conduct such examinations. When we accept claims, we obviate the need for documentation. We take the responsibility away from the claimant to provide evidence. In the face of commercial success or personal acclaim, who dares to risk collecting evidence?
....Our national political dialogue has hit a new low because complex notions, meaningful issues, and substantive suggestions cannot be conveyed in the confines of a 30-second television commercial. Content has given way to style. Let us hope that the dialogue about treatment never reaches that level. But let us do more. Let us ask those who seek to sell us ideas or machines to refrain from grandiose claims. We have the purchasing power to demand responsibility. We have the capability to reward responsible purveyors with our business and our support. And, in the face of great expectations, we can ask for evidence. The more we ask for proof, the less likely that we will be guided to false expectations.
Snake oil is snake oil—whether it's in print, on videotape, or on the Web. We still have the purchasing power and the moral obligation to use that power wisely. That means asking for evidence.
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