What we know that ain’t so

Mark Twain said "It isn’t what you don’t know; it’s what you know that ain’t so that gets you into trouble." But this may be incorrect, because the quote is also attributed to Will Rogers and Yogi Berra, among others.

Regardless of who said it, that paradigm kept appearing this past month. Rather than reading about new advances in medicine, I came across a cluster of articles that suggested prior knowledge was aberrant. Now don’t get me wrong. I know (there is that word again) that medical knowledge changes. Ben Franklin said, "In this world nothing can be said to be certain, except death and taxes." Ben Franklin is less well known for his medical research, which concluded that wet clothing and cold, damp air did not cause the common cold, but breathing putrefied air from other people in close quarters did spread disease (J. R. Soc. Med. 2005;98:534-8). Unfortunately, Ben’s arguments, which preceded the discoveries of germs by Pasteur, Lister, and Koch, still haven’t convinced Dr. Mom.

I warn medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I have no reason to believe that my teaching is any better.

My favorite example of this has been the treatment of ulcers. My medical school curriculum emphasized quantitative physiology, so we had three lectures on the nature of the gastric mucosa, acid production, protective barriers, and the potential of new medications to heal ulcers that previously would perforate and require surgery. The technique of gastric freezing, used in the 1960s, had been discredited and supplanted with the use of antacids and a bland milk diet. Unfortunately, the intake of extra calcium actually stimulated a rebound in stomach acid production. The newly discovered H₂ receptor antagonists worked better. My professors also expounded on the latest research, which showed that a new class of medications could directly inhibit the proton pump. Finally, it seemed then, modern medicine would be able to control the acid that caused ulcers, thereby permitting healing, although relapses were common. These medications quickly became the best sellers for the next 20 years. That financial success didn’t stop someone from later claiming that ulcers were actually caused by an infection, not by stress, lifestyle, and excess acid. After 2 decades of ridiculing that suggestion, the medical establishment awarded Dr. Barry J. Marshall and Dr. J. Robin Warren a Nobel Prize in 2005 for discovering Helicobacter pylori.

So it isn’t unusual for me to read articles that tell me what I know ain’t so. My first example is entitled "Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments," and challenges the effectiveness of such influenza treatments as Tamiflu (BMJ 2014;348:g2545). Local ED doctors this past winter have not promoted use of the medication in otherwise healthy children. They suggest fluids, rest, and antipyretics seem to be almost as effective with fewer side effects.

My second example is an article that asserts that circumcision may be the best thing since sliced bread (Mayo Clinic Proceedings 2014;89:677-86). If not that good, at least it is medically justified and should be paid for by Medicaid, according to those authors.

The third article contradicts data published by the Centers for Disease Control and Prevention in February 2014 and suggests that the prevalence of childhood obesity has not peaked (JAMA Pediatr. 2014 [doi:10.1001/jamapediatrics.2014.21]).

I don’t have enough space here to debate those articles. Read them and decide for yourself. I am worried about the overall state of medical research, as outlined by Dr. Richard Smith, the former editor of BMJ in his blog entitled "Medical research – still a scandal." The typical pediatrician will not wield much influence over the forces to which Dr. Smith refers. But medical students, residents, and the average physician can – and must – develop better skills at critiquing what they read.

The history of the treatment of ulcers is an excellent example of how scientific progress is made. The examples in these three articles have a different nuance. They suggest that medical research is confounding, not advancing, knowledge. And that could definitely land us in trouble.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.

Mark Twain said "It isn’t what you don’t know; it’s what you know that ain’t so that gets you into trouble." But this may be incorrect, because the quote is also attributed to Will Rogers and Yogi Berra, among others.

Regardless of who said it, that paradigm kept appearing this past month. Rather than reading about new advances in medicine, I came across a cluster of articles that suggested prior knowledge was aberrant. Now don’t get me wrong. I know (there is that word again) that medical knowledge changes. Ben Franklin said, "In this world nothing can be said to be certain, except death and taxes." Ben Franklin is less well known for his medical research, which concluded that wet clothing and cold, damp air did not cause the common cold, but breathing putrefied air from other people in close quarters did spread disease (J. R. Soc. Med. 2005;98:534-8). Unfortunately, Ben’s arguments, which preceded the discoveries of germs by Pasteur, Lister, and Koch, still haven’t convinced Dr. Mom.

I warn medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I have no reason to believe that my teaching is any better.

My favorite example of this has been the treatment of ulcers. My medical school curriculum emphasized quantitative physiology, so we had three lectures on the nature of the gastric mucosa, acid production, protective barriers, and the potential of new medications to heal ulcers that previously would perforate and require surgery. The technique of gastric freezing, used in the 1960s, had been discredited and supplanted with the use of antacids and a bland milk diet. Unfortunately, the intake of extra calcium actually stimulated a rebound in stomach acid production. The newly discovered H₂ receptor antagonists worked better. My professors also expounded on the latest research, which showed that a new class of medications could directly inhibit the proton pump. Finally, it seemed then, modern medicine would be able to control the acid that caused ulcers, thereby permitting healing, although relapses were common. These medications quickly became the best sellers for the next 20 years. That financial success didn’t stop someone from later claiming that ulcers were actually caused by an infection, not by stress, lifestyle, and excess acid. After 2 decades of ridiculing that suggestion, the medical establishment awarded Dr. Barry J. Marshall and Dr. J. Robin Warren a Nobel Prize in 2005 for discovering Helicobacter pylori.

So it isn’t unusual for me to read articles that tell me what I know ain’t so. My first example is entitled "Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments," and challenges the effectiveness of such influenza treatments as Tamiflu (BMJ 2014;348:g2545). Local ED doctors this past winter have not promoted use of the medication in otherwise healthy children. They suggest fluids, rest, and antipyretics seem to be almost as effective with fewer side effects.

My second example is an article that asserts that circumcision may be the best thing since sliced bread (Mayo Clinic Proceedings 2014;89:677-86). If not that good, at least it is medically justified and should be paid for by Medicaid, according to those authors.

The third article contradicts data published by the Centers for Disease Control and Prevention in February 2014 and suggests that the prevalence of childhood obesity has not peaked (JAMA Pediatr. 2014 [doi:10.1001/jamapediatrics.2014.21]).

I don’t have enough space here to debate those articles. Read them and decide for yourself. I am worried about the overall state of medical research, as outlined by Dr. Richard Smith, the former editor of BMJ in his blog entitled "Medical research – still a scandal." The typical pediatrician will not wield much influence over the forces to which Dr. Smith refers. But medical students, residents, and the average physician can – and must – develop better skills at critiquing what they read.

The history of the treatment of ulcers is an excellent example of how scientific progress is made. The examples in these three articles have a different nuance. They suggest that medical research is confounding, not advancing, knowledge. And that could definitely land us in trouble.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.

Mark Twain said "It isn’t what you don’t know; it’s what you know that ain’t so that gets you into trouble." But this may be incorrect, because the quote is also attributed to Will Rogers and Yogi Berra, among others.

Regardless of who said it, that paradigm kept appearing this past month. Rather than reading about new advances in medicine, I came across a cluster of articles that suggested prior knowledge was aberrant. Now don’t get me wrong. I know (there is that word again) that medical knowledge changes. Ben Franklin said, "In this world nothing can be said to be certain, except death and taxes." Ben Franklin is less well known for his medical research, which concluded that wet clothing and cold, damp air did not cause the common cold, but breathing putrefied air from other people in close quarters did spread disease (J. R. Soc. Med. 2005;98:534-8). Unfortunately, Ben’s arguments, which preceded the discoveries of germs by Pasteur, Lister, and Koch, still haven’t convinced Dr. Mom.

I warn medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I have no reason to believe that my teaching is any better.

My favorite example of this has been the treatment of ulcers. My medical school curriculum emphasized quantitative physiology, so we had three lectures on the nature of the gastric mucosa, acid production, protective barriers, and the potential of new medications to heal ulcers that previously would perforate and require surgery. The technique of gastric freezing, used in the 1960s, had been discredited and supplanted with the use of antacids and a bland milk diet. Unfortunately, the intake of extra calcium actually stimulated a rebound in stomach acid production. The newly discovered H₂ receptor antagonists worked better. My professors also expounded on the latest research, which showed that a new class of medications could directly inhibit the proton pump. Finally, it seemed then, modern medicine would be able to control the acid that caused ulcers, thereby permitting healing, although relapses were common. These medications quickly became the best sellers for the next 20 years. That financial success didn’t stop someone from later claiming that ulcers were actually caused by an infection, not by stress, lifestyle, and excess acid. After 2 decades of ridiculing that suggestion, the medical establishment awarded Dr. Barry J. Marshall and Dr. J. Robin Warren a Nobel Prize in 2005 for discovering Helicobacter pylori.

So it isn’t unusual for me to read articles that tell me what I know ain’t so. My first example is entitled "Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments," and challenges the effectiveness of such influenza treatments as Tamiflu (BMJ 2014;348:g2545). Local ED doctors this past winter have not promoted use of the medication in otherwise healthy children. They suggest fluids, rest, and antipyretics seem to be almost as effective with fewer side effects.

My second example is an article that asserts that circumcision may be the best thing since sliced bread (Mayo Clinic Proceedings 2014;89:677-86). If not that good, at least it is medically justified and should be paid for by Medicaid, according to those authors.

The third article contradicts data published by the Centers for Disease Control and Prevention in February 2014 and suggests that the prevalence of childhood obesity has not peaked (JAMA Pediatr. 2014 [doi:10.1001/jamapediatrics.2014.21]).

I don’t have enough space here to debate those articles. Read them and decide for yourself. I am worried about the overall state of medical research, as outlined by Dr. Richard Smith, the former editor of BMJ in his blog entitled "Medical research – still a scandal." The typical pediatrician will not wield much influence over the forces to which Dr. Smith refers. But medical students, residents, and the average physician can – and must – develop better skills at critiquing what they read.

The history of the treatment of ulcers is an excellent example of how scientific progress is made. The examples in these three articles have a different nuance. They suggest that medical research is confounding, not advancing, knowledge. And that could definitely land us in trouble.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.