There are in fact two things, science and opinion; the former begets knowledge, the latter ignorance. —Hippocrates

The scenario is all too familiar: an abridged version—or worse yet, the abstract only—of an emerging publication presented at a recent conference is posted on a social media website. The topic is controversial, and the findings do not echo the group’s bias. Cue the hue and cry, the righteous indignation, the steady drumming of 3 dots at the bottom of the screen as the crowd piles on to type out their displeasure. As the commentary reaches a fever pitch, the usual tropes of the ivory tower surgeon and the unheard voice of the community surgeon are invoked. There are some modest attempts by the group moderators to keep the narrative objective; these are afforded a few likes. A few swipes at the credibility of the primary investigator are thrown in for good measure. And on it goes. After roundly condemning the study, the audience moves on to the next post, having cast off the offensive conclusions in favor of their own preexisting beliefs. The full paper is not yet available for review.

From the surface, this may seem innocuous, like the natural ebb and flow of closed group discussions on social media. The conversation could easily be discarded with the same flippancy that the participants in the thread discarded the findings of the study. This type of discourse, however, belies a darker reality that should greatly concern us all. That is, the eschewing of academic publications and, by association, the peer review process.

Peer review is the process by which scholarly work is submitted to the critical review of experts on the relevant subject matter. The purposes of peer review are mainly to ensure the quality of the material presented, and also to improve upon the submitted content through the commentary of the invited reviewers.1 In theory, the yield is a well-vetted, high-quality volume of clinically meaningful information upon which physicians can base their care of patients. The reality is admittedly quite removed from the lofty intent of the system. To date, much has been (appropriately) written about the shortcomings of peer review in its current iteration. It is beleaguered by an inundation of submissions of varying quality, reviews which are not compensated and potentially (therefore) of varying quality, significant lag time in the transmission of new and significant information, and potential for bias—whether on the part of the author, the editor, and/or the reviewer. There is also an acknowledged high rate of medical reversals, where practices once standardized based on evidence are later debunked by newer evidence,2 the result of which is a slow erosion of the credibility of peer-reviewed research at its core. Some detractors also submit that many submissions are disingenuous in their intent to begin with, even going so far as to suggest the underlying agenda is self-promotion and/or financial gain. In some cases, this may be true. I hope not.

These are not the only issues, though. One of the glaring inadequacies of our medical education is a failure to establish even a basic level of competency regarding the critical appraisal of medical literature,3 leaving us with a staggering pile of information to sort through, without the tools with which to interpret that information. Notably, in the social media anecdote shared above, only 2 respondents noted the lack of availability of the full publication and the associated lack of adequate information regarding the study to establish a position related to the work. Most commentaries focused on the conclusions without knowing the most basic facts about the study design itself, and also without even a feigned attempt at intellectual curiosity around the study and how the author designed it or reached his conclusions. The confirmation bias is astounding.

Another concerning trend is the so-called “crowd-sourcing” of medical information, which is then put into use in the clinical environment. For example, some surgeons routinely post questions soliciting suggestions for best surgical approaches, recommended devices, and so on. Certainly, the presence of a forum-style discussion may yield both actionable and useful information. Still, the information provided is often not accompanied by any reference, and moreover, it is impossible to know the origin of the information or its veracity, the experience of the surgeon, or, more troubling still, any conflict of interest that the surgeon may have. Furthermore, there is no quality control measure by which to contest or remove unsafe suggestions.4 Indeed, several of the posts I have seen have suggested either surgical interventions or the use of devices for which no evidence, supportive or otherwise, exists at all. Yet, there is no discussion in these posts regarding how the surgeons are then providing a true informed consent for their patients that addresses their own experience with the procedure/device, or the level of available evidence or lack thereof. This creates an ethical dilemma for both the surgeon and the patient, both of whom are attempting to determine the best course of action with limited information. The patient, however, is at a distinct disadvantage when they are limited to making decisions with the selective information shared by their surgeons.5

While social media forums can offer an easily accessible and convenient resource to busy physicians, it would be a mistake, to say the least, to allow these to replace evidence-based medicine as the foundation upon which we offer care to our patients. Admittedly, the sheer volume of medical information continues to increase at an overwhelming rate, and educational opportunities must be intentionally and actively sought out for those not remaining in academic practice.6,7 In absence of readily available and easily digestible information, the tendency is to fall back on sometimes antiquated practices learned during training. Additionally, adherence to known guidelines is variable enough to cause great concern.8 Inexplicably, even in the face of evidence that contradicts a physician’s current practice, ineffective therapies continue to be offered.9 It should go without saying that graduating from residency does not summarily absolve us of our obligations to our patients. Our professionalism demands more.

To be clear, this is not simply a philosophical battle for the moral high ground: our complacency and lack of regard for evidence-based medicine is leading not only to unsustainable financial waste in our health care system but also, unconscionably, to patient harm.7 An oft-quoted example of this is the delivery of high-dose chemotherapy with bone marrow transplant to some 41 000 patients suffering from breast cancer in the 1990s. Propelled by a desperate public outcry for this as-yet-unproven therapy, and further compounded by political lobbying and litigation, insurers spent an estimated $3.4 billion on a treatment that ultimately failed to provide any benefit in mortality.10 Needless to say, this financial burden to society given our shared risk model for insurance is appalling. In the end, those receiving the treatment suffered from a host of acute and chronic illnesses attributable to the ineffective intervention they received, and worse yet, an estimate of up to 7% of the patients died as a direct result of that treatment.10 A series of high-quality, peer-reviewed, randomized controlled trials were responsible for reversing the practice. Still, the costs—both literal and figurative—of allowing bias to guide the treatment of thousands of patients in absence of strong evidence were and are simply untenable.

What are we to do, then, given the fundamental flaws in our current peer review system? Without question, we have a long way to go in making improvements. We can and should take measures to improve the quality of our studies and the process by which we review them, the method used to deliver that information, and the methods we use to interpret and implement it. Still, it is important to accept that we undertook the charge of being physicians with the expectation that we would utilize our critical thinking skills, combined with the best available evidence and the immutable substrate of the presenting patients, to determine the best course of action. It is incumbent upon us to hold ourselves to that standard. Our patients expect it. We also accepted that we would many times be called upon to make decisions with incomplete information. It is important to understand and acknowledge that even the best-designed, high-quality studies lack the capability for answering all clinical questions.11 It is unrealistic and somewhat narrow-minded to simply discard evidence which does not confirm our own biases, or which fails to answer all of our questions. Such binary interpretation of what is truly a nuanced entity is unbecoming in our profession, and detracts from the many vetting processes that purported to select for physicians with critical thinking skills. Rather, as with our complex relationships with other humans, we would be best served by accepting evidence with all its limitations, and realizing that we are better off in its flawed company. Indeed, it is at times the only thing standing between us and the looming unintended harm we cause to our patients.

ORCID iD

Ajita S. Prabhu https://orcid.org/0000-0003-1343-9250