There are many people in medicine who think that the intervention they use must work. Some of these are invasive and costly interventions that have modest to weak bioplausibility, but no real trial evidence
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Cute & funny paper in the @bmj_latest
But unfortunately it furthers a narrative that is detrimental to medicine and scientific progress. Many may not see why.
Allow me to explain.. [THREAD]pic.twitter.com/EFavTyMAg0
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The history of EBM shows that many of these interventions fail upon rigorous testing. So if you are a proponent of an unproven intervention, how can you avoid the call to test it rigorously?
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Enter the first
@bmj_latest article in 2003 It made the humorous case that no one would ask for an RCT of parachutes Indeed, only a fool would ask for an RCT of an intervention that improves short term mortality from ~100% to ~0%pic.twitter.com/5xUm8OeT8K
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This was cited 822 times in just over a decade. But the metaphor for medicine was always wrong. Nearly nothing in biomedicine has an ARR of 99% on mortality, most medical practices have modest to marginal effect sizes, where RCTs are vital to separate signal from noise
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Just consider the IVC filter. We keep seeing non-randomized studies on the topic, but this is because the device is on the market lacking any proper testing; So how can u avoid testing it? Hail it as a parachute? Who can say otherwise
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In 2016, Michael Hayes & I asked how many biomedical practices were really parachutes. We traced the citation record of the 2003 BMJ paper and found that it was nearly nothing in medicine https://www.ncbi.nlm.nih.gov/pubmed/29343497 pic.twitter.com/4pZbgtYFKI
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Enter the new paper. It suggests that you could perform an RCT of a parachute if you distort the trial design to a trivial hypothesis/ question.pic.twitter.com/cwOLmiR4N4
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Obviously, the metaphor is that this is what happened with COURAGE and ASTRAL and CORAL-- these trials were only negative because no one had the guts to test people with serious malady. But, that analogy would be wrong
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In biomedicine it is essential to prove that an intervention works under some circumstances. And nothing stops proponents of renal artery stenting or stenting chronic stable angina from doing just that, even 1 time, in any setting
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Even the pharma companies who I give such a lashing to in
@Plenary_Session for running bad trials, are better than many proponents of devices and interventions because they at least show this under *some* circumstances.Show this thread -
So, I think this rejoinder to the
@bmj_latest will be misused for another decade and perpetuate the mentality of no need to test what works because we already know it (original paper) and supplement it with...Show this thread -
when trials are negative of things we think work (this paper) that must be because they *excluded sickest pts *trivialized the question *insert favorite objection
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I wonder if the
@bmj_latest --- the premiere guardian of EBM -- recognizes that they are undermining their own cause. Oh well, all I can do is make a podcast!@Plenary_SessionShow this thread -
Check it out. Already being used the way i suggestedhttps://twitter.com/ajaykirtane/status/1073278344731475969?s=20 …
Brilliantly done and too bad it wasn't (at least directly) about PCI otherwise it would have made the@nytimes
https://twitter.com/rwyeh/status/1073267912037814273 …Show this thread -
On this episode of
@Plenary_Session I flesh out this discussion even morehttps://soundcloud.com/plenarysession/129-rct-of-parachutes-and-frameworks-for-internal-medicine-with-dr-andre-mansoor …Show this thread
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C’mon @VPplenarysesh, this interp is hyperbolic. Can we give the avg practicing MD a little more credit in understanding that this was brilliant satire & doesn’t
importance of RCT. Highly doubt this is going to have the negative impact you think it will -
I encourage you to read the 822 articles (now 900+) that referenced the original parachute paper. We did.
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1. No tks 2. Really? All 822. Maybe I misunderstood the methods section? 3. 35/822 made the parachute argument. A bit underwhelming. Hardly undermines value of well done RCTspic.twitter.com/a5LrCEnfMJ
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35 named names - they specified a medical practice that is akin to parachute. Hundreds and hundreds used the BMJ paper to disparage, malign and trash RCTs generally-- those were not pertinent to our study q. We wanted naming names. We reviewed the full texts.
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just not the full text of the few veternary articles, or not in english.
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