I have the task of digitising my old man’s writings. He was a psychiatrist, working everywhere from the prisons to the air force as well as a private practice. He seems to have written about eleventy billion articles going by the folders still to be copied. I can forgive him, because most of the time he was deflating the pompous.
I invite you to enjoy a little excerpt about medical publishing from 30 years ago which shows not much has changed since then. Please extend the reference to ‘Medicine’ to include ‘The Arts And Social Sciences’.
I would like to consider the proposition , commonly advanced, that the material published in medical journals is scientific. Imagine that I am a scientist, and that the object of my study is swans. As a result of some observation and some thought I have formulated the hypothesis that all swans are black. You will note that it is a good hypothesis, not only be cause it can be understood by anyone prepared to listen, but also anyone who takes the trouble to inspect swans will be able to refute it, if indeed it is incorrect. Additionally, it motivates us to make further observations of swans: we have science at its best.
In the course of my enquiries I go to the zoo, and there I observe a white swan. My hypothesis is refuted: I retreat, cogitate and then declare a new one, ‘all swans are achromatic’. Once more it is refutable: discover but one coloured swan, plain, polka dotted or even tartan and I must hypothesise again. This, as I understand it, is scientific activity: the construction of refutable hypotheses which are then tested so that we will be led to better ones. We approach the truth asymptotically, but we never achieve it. Remember that a refuted hypothesis may be most useful nevertheless: think, for example, of those hypotheses of Newton which not only still serve us well, but also caused other great minds to work so hard to produce better ones.
Now let us change tack a little. My initial paper about swans would have been brief and to the point. ‘Having observed a number of swans, it is my hypothesis that all swans are black. I would be grateful if any observations of swans inconsistent with this hypothesis were forwarded to me at the above address.’ The second paper would be no longer. ‘I refer to my previous hypothesis, namely that all swans are black. This hypothesis has been refuted by my observing a white swan. I now propose that all swans are achromatic. Once more, observations to the contrary would be much appreciated.’ Note, by the way, that I regard refutation of my hypothesis as a step forward, not as the destruction of a cherished possession.
Now, I imagine that as I continue my advance into pure science, other papers might begin to appear. First one might encounter: A Portable Digitalised Telecolorimeter for Examining the Plumage of Swans at a Distance by A, B and C.
Succeeding papers might be a function of the interests of the day – thus we might confidently anticipate: A Search for Endorphins in the Faeces of Chenopis Atra to by D, E and F, rapidly followed by A Double Blind Controlled Trial of Six Beta Blockers in the Arctic Nesting Whistling Swan by G, H, I, J and K, repeated as many times in as many journals as there are permutations and combinations of the authors’ names. There might be a paper on A Special Apparatus and Wetsuit Combined to Permit the Endoscopy of Swans While Swimming: those of you familiar with current literature will be able to invent further titles of your own. Certainly, after a time the literature would become self generating, able to continue even if all swans in the world were to perish. Under these circumstances we might have A comment on the use of non parametric statistics in Duddlethorpe’s Analysis of Honking Behaviour in Swans, including Cygnus Dolor, the mute swan. And then, A Reply.
Finally, of course it would spill over into other.literatures. Swan Upping: some radical feminist strategies for introducing new therapeutic modalities into the management of high socio-economic status zoophiles.
Our literature is launched. We can assume that PhD’s and MD’s are already being won and that a portfolio filled with nonsense of this kind may well lead to rapid academic achievement. Before long I shall receive on my desk prospectus, posted direct from Ruritania, inviting me to subscribe to the new International Journal of Swanology. The first issue will be of some five hundred pages and contain a distillation of the wisdom revealed at the 1979 International Conference. No doubt by coincidence, the Editorial Board of the journal will bear a remarkable resemblance to the list of contributors.
Every article will have the same conclusion – ‘Under standard experimental conditions X numbers of Y things were submitted to procedure Z. Using statistical procedure A , and computer programme B, it has been demonstrated that there is reason to believe that further research in this area may be beneficial. The authors wish to express their gratitude to Miss Helga Futt for her typing, and to the Cornucopia Institute for their funding’. Meanwhile, no one has produced a coloured swan.
Now what is all this? Science? I think not – rather it is an industry. We have people counting things in the hope that some thing will turn up, obsessionals who believe that measurements are worthy ends in themselves, plagiarists, pragmatists who see how to get on, masseurs of data and – mixed up with it all – a handful of scientists and savants – diamonds in porridge.
Needle in a haystack
If you find all that unconvincing , then let me come at it another way. A couple of years ago I had an illness which kept me busy for a while, and made it necessary for me to postpone many things, of which one was my scrutiny of the literature relevant to my daily tasks. In the long run I found myself confronted with a year’s journals, which in time were subdued. When I finished dealing with them I asked myself what benefit that rather cheerless exercise had produced – in what way was my practice changed as a result of my labours. The answer came readily enough, for there was only one element in it – I was even more concerned about the lithium – haloperidol interaction than I had been when I started. For one year’s reading this was not much of a yield.
But perhaps all that is but a demonstration of my own personal limitations, so let us try another perspective. Writing about psychiatry is difficult. Some of it cannot be quantified at all, like music. It is difficult for pseudoscientists to get a foothold there, for you have to do your own thinking and measurement doesn’t help. Further, if you do happen to write something intelligent or interesting, those programmed to respond to words like double blind and chi square are not triggered and will pass you by. Promotion does not lie that way. However, there are aspects of psychiatry which can be measured with good reliability, (let us not worry too much about validity) reduced to numbers, and then spun into webs of factors, variances and God only knows what else sufficient to satisfy anyone. From that point of view one of the simple tasks is to investigate the treatment of depression; there is plenty of it around, its subdivisions are manageable, and there are some effective remedies in existence. All systems are go: if you wish to start a career in research, start there.
What has happened? In the last 12 months, as part of a quality assurance project of the RANZCP and the University of New South Wales, researchers at the latter constructed a bibliography of the treatment of depression.
The successful treatment of depression requires patience and much tying up of loose ends, particularly in the case of neurotic depression. This in turn requires time and one would be reluctant to be comfortable about outcome with less than three months’ observation. Nevertheless, in the 100 acceptable studies, the median time for the duration of treatment, and for the time from the beginning of treatment to the assessment of its results, was four weeks. Only one study in eight had followed patients for the three months or more which any clinician would regard as necessary. Even when the trial was between two effective treatments, the median duration was still four weeks indicating that the researchers were more interested in getting quick answers to pharmacological questions than they were to discovering what happened to depressed people. Few of the studies produced data on compliance, a major issue in all pharmacological treatment in psychiatry. I should mention that the paper which produced the best results of all was impeccable in its design and revealed that two chemicals long since departed into the history of psycho pharmacology were much more effective than anything else. The firm producing one of the remedies had funded the trial.
Large haystack, small needle
I could go on but let me make my point clear. I do not assert that all medical literature is trivial, incompetent or faked. There are numerous papers of wisdom and perspicacity and without them the various disciplines of medicine would stagnate. What I do say is that an unfortunately large proportion of the medical literature is repetitive, uninspired and created more for the advancement of the authors than for the advancement of medicine. Further, much of it has very little to do with science.
Moreover, the relevance of much original medical literature to most medical practice is marginal. The more learned the journal the less its creators will be concerned with discovering the needs of its audience, which is why there is a steady proliferation of more and more specialised journals. Eventually one reaches a state in which the only people who read a particular journal are those who write it – we have passed from incest to masturbation.
The gap between what authors write about and what practitioners do is more noticeable if one looks back at the journals of say thirty years ago. Indeed, as you read them, you will find it difficult to decide what the practitioners of the day did at all. A friend of mine, eminent as a practitioner as well as an editor, once told me that he enjoyed using the library at Harvard, for there the journals are bound with their advertisements still in them. From the advertisements he managed to get a feeling for what was afoot in those days.
JOURNAL OF GENERAL PRACTICE JANUARY. 1984 pg. 11