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How do we know what we know? Medical Grand Rounds featuring Dr. Richard Veldhoen

Kathleen Harrison, PhD Candidate, Neuroscience Studies

Physicians strive to practice medicine in a manner which provides the greatest likelihood of benefit towards their patients. To do this, a clinician develops their medical judgement though extensive training experiences, but also, through information outlined by the most recent guidelines and research in their specialty. Important to this, is time spent understanding novel research. Keeping up with the literature provides the opportunity for clinicians to prospect information which may better inform their practice, but has yet to become integrated into mainstream care. A key example of this is the KSHC Medical Grand rounds, where researchers are invited to present their own research activities and how it may improve medical care. However, a main assumption in learning from novel research is that the quality of evidence being presented is sound and that the conclusions drawn are an accurate.


Unfortunately, not all research is equal. Though it was historically difficult to find new information -- and acceptance into a journal was a great accomplishment -- we now live in a world where the availability of information is not the issue, but rather sifting through available information to find high-quality data.  Indeed, we often hear news stories regarding the internet crisis of “fake news” and biased media. Medical research, too, is experiencing such a crisis. Thus, critical analysis of evidence from medical research is now of utmost importance to clinicians.  


On March 28th, Internal Medicine Resident Dr. Richard Veldhoen used Medical Grand Rounds (MGR) as an opportunity to educate clinicians on critical evaluation of medical research and the principles of evidence-based medicine. The core theme of the presentation was that not all evidence is the same, and there exists a hierarchy of evidence.


To help with rationalizing this concept, Dr. Veldhoen made the analogy that evidence is like a pyramid. Low quality evidence is placed at the bottom of the pyramid -- and though not necessarily of great clinical use –this research provides a foundation to develop more rigorous scientific investigations. At the top of the pyramid is high quality evidence, which is of more limited supply, but can be thought of as a refined result of the information bellow it.  Non-evidence based research --like opinion pieces and case studies-- are placed at the bottom of this pyramid. This is followed by more clinically detached investigations, such as basic science and pre-clinical research, then follows observational cohort studies. Near the top of this pyramid are randomized controlled trials. At the very top of the evidence pyramid are systematic reviews and meta-analysis. Thinking of scientific research this way is beneficial, as it allows an intuitive description for how to evaluative investigations, and it is often an accurate reflection of scientific certainty.  However, this ‘pyramid’ may also be too simplistic. Indeed, there are numerous instances of poor-quality meta-analytic studies. Simply because a manuscript is reported to be a ‘meta-analysis’, that does not suggest that it is a quality paper. Thus, there is great importance for investigating both the value of the chosen study design in addition to the methodological particulars of the research being reported.


Following Dr. Veldhoen’s MGR presentation, the Translational Medicine Graduate Class had an opportunity to speak with Richard in greater detail on his presentation. During this discussion, Dr. Veldhoen pointed out the importance of issues facing doctors regarding evaluation of evidence. Specifically, he thought it is unrealistic that doctors are expected to understand complex statistical techniques, which are often distant or absent from their daily practice. Coming from a background in statistics, Dr. Veldhoen mused that statistics is a specialty in itself; how should doctors be expected to be effective in their clinical care while also learning the nuances of effective scientific and data analytics? Indeed, much like the Dunning–Kruger effect, it may be that the small amount of research experience forced on students may result in young-clinicians having cognitive biases regarding their ability to interpret research findings.


Dr. Richard Veldhoen suggested that -- though there should be basic education regarding evaluation of evidence-- medical educators should be cautious regarding forcing research and statistics on medical students. For young students trying to ‘learn the ropes’ of medical practice it may be educationally unreasonable, and fiscally irresponsible, to require research during undergraduate education.  Additionally, he believed that incentivizing undergraduate research output, though increased resident placement and granting opportunities, can incentivize prolific publication records of low quality research. Similar to the opinion of Dr. Michelle Lamarche, another internal medical resident, Dr. Veldhoen believed that young Physicians should be encouraged, and rewarded, in pursuing professional development opportunities targeted towards their interests, which may not include research.  


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