Transcript Research in Obstetrics and Gynecology

Research
in Obstetrics and Gynecology
R.A. Pierson, MS PhD
Professor, Department of Obstetrics, Gynecology and
Reproductive Sciences
College of Medicine
The Problem
“I don’t know…”
“I don’t really care about
all of this research stuff…”
“I just want to take care of patients…”
Unnamed Ob-Gyn Resident III
at OB-GYN Research Day 2000
The Solution
“I can’t think of a better way for
you to care for your patients than
to do research!”
Practicing clinician and part-time faculty member
OB-GYN Research Day 2000
Training
To guide or teach something as by subjecting to
various exercises or experiences
To guide or control toward a specific goal
To do exercises that prepare for a specific purpose
To improve or curb by subjecting to discipline
Education
The act or process of acquiring knowledge
The knowledge or training acquired by
this process
The act or process of imparting
knowledge
The theory of teaching or learning
Education implies a continuous process !
We need to blend these two
concepts into a coherent whole
To improve patient care and quality of life
Imparting the knowledge in our discipline
to the next generation
Evaluate the effectiveness of our therapies
and interventions
Apply new technologies to old problems
Create and disseminate new knowledge
An Obstetrical Case Study
Queen Anne was the last Stuart monarch of Great
Britain.
In the last 17 years of the 17th Century, she was
pregnant 18 times.
Only 5 children were born alive, only 1 of them
survived infancy.
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He died before reaching adulthood.
There is no evidence of a genetic disorder
Queen Anne had the best medical care
money could buy.
What is Research ?
Research is simply a process by which we
answer a question using a set of rules called
the scientific method.
The Scientific Method
Make an observation
Formulate an hypothesis
Design an experiment
Execute the experiment
Analyze the results
Draw conclusion
Formulate a new hypothesis
Scientific Method
In science, we may start with experimental results, data,
observations, measurements, “facts”.
We invent a rich array of possible explanations and
systematically confront each explanation with the facts.
We employ a “baloney detection kit” which is brought
out whenever new ideas are offered for consideration.
If the idea survives examination by the tools in our kit,
we grant it warm, although tentative acceptance.
Critical Thinking
The end result of learning the scientific method
Should reduce biased assertion or uncritical
acceptance of ideas in the day to day practice
of obstetrics and gynecology
The fact that an opinion has been
widely held is no evidence
whatsoever that it is not utterly
absurd.
Bertrand Russell
What is Research ?
Research is to see what everyone else
has seen, and to think what no one else
has thought.
What is Research ?
Pierson’s Corollary
If we knew what we were doing,
they wouldn’t call it research!
Hippocrates ~ besides the oath
Hippocrates of Cos introduced elements of the
scientific method into the diagnosis of disease in
the First Century BCE.
He stressed careful and meticulous observation.
He recommended that physicians be able to tell,
from present symptoms alone, the probable past
and future course of each illness.
He was willing to admit the limitations of the
physician’s knowledge.
Hippocrates’ Teachings
“Leave nothing to chance.”
“Overlook nothing.”
“Combine contradictory observations.”
“Allow yourself enough time.”
Hippocrates, 1 BCE
Medicine in Classical Times
Although considerable further advances in
medicine were made in classical times through the
fall of Rome. What followed in Europe was truly a
dark age.
Much knowledge of anatomy and surgery were
lost. Reliance on prayer and miraculous healing
abounded. Secular physicians became extinct.
Chants, potions, horoscopes and amulets were
widely used.
Medicine in Classical Times
Dissections of cadavers were restricted or
outlawed, so those who practiced medicine
were prevented from acquiring firsthand
knowledge of the human body.
Medical research and advancement of medical
knowledge came to a standstill.
Such is the fruit of “Prohibitions”.
History of Medical Research
In the revolution of ten centuries, not a single
discovery was made to exalt the dignity or
promote the happiness of mankind. Not a single
idea had been added to the speculative systems
of antiquity, and a succession of patient disciples
became in their turn the dogmatic teachers of the
next servile generation.
Edward Gibbon, History of the Eastern Empire,
It has come to our ears that members of both
sexes do not avoid to have intercourse with evil
angels, incubi, and succubi, and that by their
sorceries, and by their incantations, charms and
conjurations, they suffocate, extinguish, and
cause to perish the births of women. Pope Innocent VIII
Papal Bull, 1484
With this Papal Bull, Innocent initiated the systematic accusation,
torture and execution of “witches” all over Europe. The Inquisition
had begun. Such is the value of “authority.”
What is Science ?
Science is more than a self-correcting body
of knowledge; it is a way of thinking.
Science is far from a perfect instrument of
knowledge; it is just the best that we have.
The scientific way of thinking is at once
imaginative and disciplined.
When we are self-indulgent and uncritical,
when we confuse hopes and facts, we slide
into pseudo-science and superstition
Tenets of Evidence Based Medicine
“Everyone’s clinical opinion counts equally, regardless of rank or
experience. We value opinions only to the extent that they are
supported by scientific evidence, and not according to the
perceived prestige of the proponent. When a clinical question
arises, we address it as a group through formal review rather than
by edict from the faculty. To suggest that more experienced
clinicians are inherently better able to understand science strikes
me as elitist. Science abhors authoritarianism (and has little use for
age discrimination). With increased age, we tend to expect
increased wisdom; however, sometimes, the years bring only a
narrowing of the vision and a hardening of the arteries.”
David Grimes, Evidence Based Medicine, Obstetrics & Gynecology 86(3) 1995
What is Science ?
It invites us to let the facts in, even when they do not
fit our preconceptions.
It counsels us to carry alternate hypotheses in our
heads and see which best fit the facts.
It urges us on a delicate balance between no-holdsbarred openness to new ideas, however, heretical,
and the most rigorous skeptical scrutiny of
everything - new ideas and established wisdom.
This tool is essential for a democracy in an age of
change.
Carl Sagan, 1996
Scientific Illiteracy
Two recent surveys are interpreted to mean that 95% of
the North American population is scientifically
illiterate.
We live in a time where the consequences of scientific
illiteracy are far more dangerous than in any that has
come before.
Real-life examples of scientific illiteracy in OB-GYN
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Blood letting in pre-eclampsia
“Twilight Sleep” with no regard for the baby
Science Precepts
Every time a scientific paper presents data, it is
accompanied by an error bar - a quiet, but insistent
reminder that no knowledge is complete or perfect.
The error bar is a calibration of how much we trust
what we think we know.
If the error bars are small, the accuracy of our empirical
knowledge is high; if the error bars are large, then so is
the uncertainty of our knowledge.
Science Precepts
Humans crave absolute certainty; they may aspire to it;
they may pretend to have achieved it; but the history of
science tells us that the best that we may hope for is
successive improvement in our knowledge.
We will always be mired in error. The most each
generation can hope for is to reduce the error bars a
little.
Skepticism is the prime tool in any explorer’s toolkit,
if not, we lose our way.
Science Precepts
One of the great commandments of Science is
“Mistrust arguments from authority.”
Authorities must prove their contentions, just like
everybody else.
There are no forbidden questions in science, no
matters too delicate or sensitive to be probed.
Openness to new ideas, combined with the most
rigorous, skeptical scrutiny of all ideas, sifts the wheat
from the chaff. It makes no difference how smart,
august or beloved you are.
Science - Why do we put up with this?
Do we like to be criticized?
Every scientist/clinician feels a proprietary
affection for his or her ideas.
The hard rule is that if the ideas don’t work, you
throw them away. Don’t waste neurons on ideas
that don’t work.
Devote those neurons to new ideas that better
explain the data.
Valid criticism does you a favour.
It is a capital mistake to theorize before
one has data. Insensibly, one begins to
twist facts to suit theories, instead of
theories to suit facts.
Sherlock Holmes
in Arthur Conan Doyle’s
A Scandal in Bohemia, 1891
The Tool Kit for Skeptical Thinking
We will not learn much from mere contemplation.
How do we decide among competing hypotheses?
We let experiment do it.
Control experiments are essential.
Variables must be separated.
Often, the experiment must be double blind so that
those hoping for a certain finding are not in the
compromising position of evaluating the results.
What should we do in OB-GYN?
Be skeptical
Question authority
Make observations
Live and work experimentally
Draw rational conclusions
Do not overstate your data
Goals
Open avenues for exploration of the human condition
Well-designed framework within which to work
Improve reproductive health care for Canadians and
the global community in all its many meanings
Understand the impact of our interventions
 On the children born
 On women and their families
 On future generations
Goals for Obstetrics &
Gynecology (and ...ists)
Foster an integrated research-clinical
medicine-community approach
 To
the creation of new knowledge
 To the provision of clinical services in
women’s health care
 To improving the human condition
Truth or Consequences
The consequences of a lack of research
interest among physicians are that health
purveyors over the conduct of research and
making health policy.
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e.g., HSURC in Saskatchewan has a goal of
curtailing clinical practice in some areas
If we do not do this ourselves, it will be
done for us
Important Points to Be Considered
Practice of medicine will change with completion of
the human genome project from a diagnosis and
treatment model to one of discovery, prevention and
management of disease.
We are on the leading edge of a wave of incredible
discoveries in Reproductive Science & Medicine.
Many of these discoveries will challenge some of our
most closely held beliefs.
Important Points to Be Considered
Reproductive Science & Medicine have
immense medical and social implications
Enormous strides have been made in
maternal health and peri-natal care in the
developed world
Reproduction remains a lottery
An Eye to the Future….
Priorities for Reproductive Science and
Medicine in the next century will be
to optimize safety of reproduction for mother,
father and child
 to prevent diseases afflicting the reproductive
systems,
 to overcome infertility in both sexes, and
 to address the numerous consequences of arrested
ovarian and testicular function with advancing age
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How Has Our Understanding Changed?
Where are We?
Pills, potions and patches
are ubiquitous in
Obstetrics & Gynecology
“The Pill” has profoundly
changed our concepts of
reproductive choice
New choices being
developed monthly
Information is what we try
to give our patients
Where Would We Be Without It ?
Today’s research
is tomorrow’s
medicine
Reproductive Technology
Simple to say.. More difficult to understand
Has changed our notions of reproduction
“Progress” is highly controversial
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ICSI
IVM
In vitro gestation
Stem cells
To Clone, or Not to Clone
Etc….
WOW.. What a future we’ll have…!