Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St. Pomona, CA

Show Me Your Poor, Your Tired,
Your Huddled Cases

This week I'd like to bring up a small gripe I have regarding how doctors present and discuss medical issues with each other. Whenever I attend conferences, I currently expect to see lectures in which the speakers show us their best cases, the perfectly performed triple arthrodesis, the bunionectomy with an intermetatarsal angle of 30 degrees that was completed without any shortening or problems, or the completely destroyed pilon fracture magically made whole without a hint of postoperative arthritis. Similarly, it's well known that throughout the history of medical publication, there has been a bias toward publishing only "positive" research results. This even has the name of "publication bias."

I wonder just how detrimental this publication bias is and how different our conversations and overall knowledge would be if we were more honest with each other (and ourselves) about the results of our medical and surgical care?

Conference Biases

Let's talk first about presentations at conferences. First of all, if I hear the phrase "in my hands" at another podiatric conference, I just might vomit. What do I care if your version of procedure X is successful when performed by you? Are you going to take care of all my patients who need procedure X? Unlikely. Also, how likely is it that at a national conference, you're going to show everyone that case that just didn't go well or had a substandard result? It happens to all of us, and if you say it doesn't happen to you, then you're just lying.

Therefore, I propose we outlaw any phrase with a meaning similar to "in my hands." If one of our national lecturers says this, the crowd should be able to mob the stage, screaming, with mouths foaming in lunacy, eyes bulging, ready to tar and feather the speaker...

Tonight's Premier Lecture is
Venous Leg Ulcers:
The Forgotten Vascular Disease
Robert Kirsner, MD

...OK, maybe that's a bit too far. Maybe they should instead not be allowed to return to speak at the next conference. Much less dramatic, I know, but probably more effective.

On the other face of the coin is the very rare "complications" type of lecture. At the last two Western conferences I attended, they had one of these lectures. A panel of brave speakers got up and showed their worst cases. Granted, a couple of them were not that bad, but there were some really unfortunate surgical results.

Here's my suggestion. All conferences should have several of these "complications" lectures. We need to put them on the docket during the main days of the conferences where the largest numbers of attendees are likely to see them, rather than on Sunday at 11 AM when most of us have already left. Maybe the conference leadership should demand all speakers to show one case where things went wrong and how either they handled it or should have handled it. We'll all learn something from them. We would learn more from these cases than any of those "review" lectures where the speaker tells me a bunch of stuff I already know.

This brings me to the "review" lecture. Outside of the typical board review lecture, specifically designed for those taking their boards, we should force the elimination of the "review" lecture. Who cares what Hardcastle and Myerson stage that Lisfranc fracture is? I want to go to a lecture that tells me something I don't already know, something I can actually use when I go to the office.

Here's a simple way to eliminate the review lecture. Conference organizers should instruct all of their speakers to make an argument of some type based on some thesis. For example, maybe speaker Y will argue that all bunionectomies should now be done with the Lapidus procedure (I'm not actually advocating this…yet). Or perhaps a wound care lecture would try to convince us to stop using certain topical medications. These lectures would synthesize and analyze the current research to argue and support their thesis.

Here's a quick example. A couple of years ago, I gave a local Southern California lecture arguing that surgical care for diabetic foot ulcers is superior to nonsurgical care. I argued that nonsurgical care is not always conservative, foot surgery is safe in diabetics if rationally planned, surgical care is highly successful, and the stakes are very high, requiring a more aggressive approach. I used the current literature to support my argument and, hopefully, provided a lecture that was worth seeing.

Similarly, Paul Scherer, DPM made a strong argument for the importance of shear forces on the formation of diabetic foot ulcers at a recent conference I attended. I learned something and gained a new tool to help my patients.

Bias in the Medical Literature

I'll conclude my gripe with the medical literature. Publication bias is huge in the medical literature. Just think how many studies you've read recently that demonstrate a poor or suboptimal result.

Song and colleagues performed a systemic review of studies looking for publication bias.¹ Not surprisingly the authors found the following results:

Studies with significant or positive findings were more likely to be published than those with insignificant or negative findings.
Studies with significant or positive findings were published earlier.
Published studies reported a more significant treatment effect than "grey" literature (research not formally published).
Exclusion of non-English-language studies increased the risk of publication bias.
A potential detrimental effect was seen in some cases when publication bias was high.

Similarly, a Cochrane systematic review that searched a cohort of meta-analyses found that published trials tend to be larger and with a greater treatment effect than grey trials. They recommended that future meta-analyses consider the inclusion of these grey trials in their results to minimize publication bias.²

I think it's time for us to be more honest with ourselves and our colleagues and start looking at the "grey" side of our work. We're likely to learn as much or more from mistakes and poor results than all of our "successes" (if that's what they really are). Let's start being critical of our lecturers, researchers, and ourselves.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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References:

Song F, et al. Health Technol Assessment, Feb 2010; 14(8): 1-220.
Hopewell S, McDonald S, Clarke MJ, Egger M. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: MR000010. DOI: 10.1002/14651858.MR000010.pub3.