We are in an age of high speed. Lightning fast searches for information and the perception that this yields quick results. John S. Rinehart MD, PhD and a Partner with Reproductive Medicine Institute with offices throughout the Chicago area, reminds patients “Efficiency doesn’t necessarily produce efficacy. In medicine, the first answer is not always the right one and it is part of the physician’s role to separate fact from fiction.”
The lead article in the April issue of Human Reproduction, a leading journal in the field of Reproductive Endocrinology and Infertility (REI), deserves attention as it addresses this very point. The article cautions specialists in REI to be watchful as to how the current literature is interpreted. The article targets physicians but the message if highly relevant to all patients experiencing infertility.
SEEING ISN’T BELIEVING
The issue arises because of the wide access people have to information, given today’s internet community. Two things which need to be considered are ‘confirmation bias’ and the enormous, freely available amount of information online.
Confirmation bias is a subconscious practice that all people employ when they search for information that will confirm an impression that they have. In other words, the process is to formulate an idea, for example ‘that natural IVF is better than stimulated IVF’, and then search the internet for articles that confirm this impression. This process is an unavoidable consequence of how the human brain works. The best way to counteract this process is to be aware of the fact that decisions may be made based upon a false prediction which in turn creates biased data collection.
The second problem is the vast amount of information that is available. Almost any reasonable impression can be confirmed if enough effort is made to search the internet. The internet makes no effort to evaluate the quality of the information or the truthfulness of the data. Physicians practice what is called “evidence based medicine” which organizes research data in order of accuracy. The gold standard has been the randomized controlled trials where two groups are compared randomly. The least credible evidence is the case report where a physician reports what he found on a single or a few cases. This last form of information is analogous to what a friend or relative relates to a patient.
PROCESSING THE PROOF
The article by Evers published in April calls into questions the quality of the gold standard. This is concerning to physicians because if a physician is making a recommendation for treatment to a patient, relying upon a single Randomized Controlled Trial, this may not be the best recommendation. For a patient searching the internet, reliance upon an apparently sound research publication may in fact be inappropriate for that patient.
Two examples from the article seem relevant. The first is that Professor Evers has published that “less than 15 % of all research reaches publication AND is well reported, AND is methodologically sound.” The second is an example of what is called the “Texas Sharpshooters Fallacy”. The fallacy concerns a Texan who randomly fires a number of shots at the side of a barn. He then draws a circle around the holes in the barn and claims he is a sharpshooter.
Given this frustrating situation, it is understandable if a physician or patient throws up their hands in exasperation and wonders what to do. One thing is to completely ignore all data and just do what makes sense. Unfortunately, medicine is full of things which made sense that were completely false. A more productive approach is to collect as much information as possible and work with a physician as a physician- patient team to arrive at an informed decision about treatment options. At the end of the day, the value of research and data is to help make decisions which will be the most accurate way to meet the goal. “No decision will be accurate all of the time,” says Dr. Rinehart. “So, the ultimate goal is to reduce the uncertainly about the uncertainty when making decisions about healthcare. The decision is a balancing act between risk- benefit- cost. A mutually agreed upon plan of action to completion will help a patient resolve their fertility issues.”