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How the growth of denialism undermines public health Espousing unproved myths and legends is widespread during the festive season, but some groups hold views contrary to the available evidence throughout the year. This phenomenon, known as denialism, is becoming more elaborate and widespread, and poses a danger to public health, say Martin McKee and Pascal Diethelm
hristmas is a are not. Unfortunately, time when many confusion is encouraged entirely rational by the liberal use of the people whose term, such as when the views are based current British govern- Csolidly on empirical evi- ment uses the term “def- dence the rest of the year icit deniers” to attack suspend their critical fac- critics of its economic ulties and say things they policy, a group that now know to be untrue. Just in includes large num- case any young children bers of distinguished have picked up their par- economic researchers, ents’ copy of the BMJ, we among them several won’t go into detail except to Nobel laureates.8 say that the subject of these Although contempo- falsehoods traditionally rary usage of the term originates in the far north.1 is relatively recent, the Such stories are harmless concept of denialism and those telling them will, has been recognised
when their children reach GERARDOGARCIA/REUTERS for several decades. A an appropriate age, abandon chapter entitled “Denial the pretence. Yet other people hold views that Denialism and its history of reality” in a 1957 book describing the are equally untrue and do so with an unshake- The term “denialism” has been coined to phenomenon of cognitive dissonance notes able faith, never admitting they are wrong describe this phenomenon. First popular- how “. . . groups of scientists have been known however much contradictory evidence they ised by the American Hoofnagle brothers, to continue to believe in certain theories, sup- are presented with. one a lawyer and the other a physiologist, porting one another in this belief in spite Some of these views are harmless, but it involves the use of rhetorical arguments of continual mounting evidence that these others cost lives. It is easy to think of con- to give the appearance of legitimate and theories are incorrect.”9 It highlights, in par- temporary examples. “HIV is not the cause unresolved debate about matters generally ticular, the importance of selectivity, whereby of AIDS.”2 “The measles, mumps, and rubella considered to be settled.6 The term can be “one aspect of the process of dissonance reduc- vaccine cannot be considered safe.”3 “Second traced to people who deny the existence of tion [is] obtaining new cognition which will be hand smoke is simply an irritant and there the Holocaust, but it has subsequently been consonant with existing cognition and avoid- is no conclusive evidence that it is danger- applied much more widely. Denialism can ing new cognition which will be dissonant ous.”4 And, with potentially the greatest be recognised by the presence of six key fea- with existing cognition.” The extent to which consequences for our species, “the evidence tures (box).6 7 It is, however, important not to selectivity influences our views is now widely that the world is warming is inconclusive, confuse denialism with genuine scepticism, recognised, not least as a result of a best sell- and, if not, the evidence that global warming which is essential for scientific progress. ing book containing many examples of what is is caused by anthropogenic carbon emissions Sceptics are willing to change their minds termed “confirmation bias.”10 One explanation is unproven.”5 when confronted with new evidence; deniers is that confirmation bias is how we deal with
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evidence that challenges our Change inappropriately ref- strongly held beliefs and that erenced a statement on a would otherwise threaten our report about the sensitivity self perceived status as intel- of the rainforest to changes ligent and moral individuals. in rainfall rather than the relevant primary research. Approaches to denialism This inconsequential refer- Recent cognitive research, encing error, in a report of some taking advantage of more than 900 pages, was advances in brain scanning, then used to undermine the has shed light on the neuro- entire report.18 logical processes whereby indi- Deliberate falsehoods are viduals interpret a message rarely used to convince peo- according to who is the mes- ple that something is true, senger. People subconsciously but rather are used to seed suppress recognition of clearly doubt about the actual truth. contradictory messages from For example, although only politicians that they support, 18% of Americans believe yet easily identify contradic- that President Barack tions from those they oppose.11 Obama, a church going However, simply ignoring rel- Christian, is a Muslim, an evant evidence is insufficient. additional 43% are unsure.19 Evidence, including authori- Media commentators don’t tative corrections, that contra- actually say that that Obama dicts strongly held views can, is a Muslim, they just say that paradoxically, reinforce those they don’t know whether he views.12 Thus, research in the is or he isn’t, while consist- United States has found that ently using the president’s registered Republicans who full name: “Barack Hussein are exposed to evidence on the Obama.” In the health arena, importance of social determi- this approach is commonly nants of health are less likely found in debates about vac- to support collective action to cines, where denialists play address them than are those As with vaccines, you can never be sure on the argument that “you not exposed.13 can never be sure” when it Yet denialism involves more than someone initiative would have redefined a relative risk comes to the very small risk of complications accumulating a collection of individual errors of less than two as being not statistically sound of vaccinations. in information processing. Increasingly, it because of the potential for unrecognised takes on the form of social movements in confounding and was designed to exclude The spread of denialism which large numbers of people come together research on the risks associated with passive Of course, there have always been people who and propound their views with missionary smoking, which typically yield a relative risk have held strong views in the face of over- zeal.14 These views combine exploitation of the of 1.3-1.6.16 Other efforts seek to redefine con- whelming evidence to the contrary. Indeed, genuine uncertainty that characterises scien- cepts as essentially unresearchable, such as the Flat Earth Society, although a shadow of its tific research with the use of simple falsehood. in an industry funded report on alcohol that former self, still exists. However, the world has Denialists emphasise the limitations of stated: “violence is a nebulous concept.”17 changed in recent decades in three important statistical associations for establishing causal- Selective use of the scientific literature is ways, each facilitating the spread of denialism. ity, which are well recognised by aetiological another approach used by denialists, who The first is the birth of web 2.0, which has epidemiologists, yet ignore other criteria that either promote methodologically flawed transformed the internet from a closed pub- are used to ascertain whether a relationship is research that supports their world view over lishing platform into an interactive tool allow- likely to be causal, such as biological plausibil- more methodologically sound papers or ing intensive exchange of ideas. People who ity, consistency, and strength of association.15 undertake intensive searches of papers they might once have clung on to dissenting views They may also try to change “the rules of the oppose for anything that might cast doubt on in isolation can now locate individuals with game,” such as in the now notorious example the quality of the science. A now notorious similar views within seconds. Social media when the tobacco industry sponsored efforts example is “Amazongate,” in which a report enable communities of denialists to grow by to define “good epidemiology practice.” The by the Intergovernmental Panel on Climate feeding each other’s feelings of persecution by
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When a seemingly bizarre story appears in the media that risks undermining public health, health professionals should ask: “why is this story appearing now?”
a corrupt elite. This is encouraged by cynicism tackle HIV/AIDS in east Africa had to address CHARACTERISTICS OF DENIALISM with existing political systems. In one study, concerns that promotion of condoms was a Identification of conspiracies: Denialists argue for example, the people who were most likely covert attempt to control the population. It that scientific consensus arises not as a result of independent researchers converging on the to believe in 9/11 conspiracy theories were may be necessary to accept that there are some same view but instead because researchers those who were disaffected and disengaged people who cannot be convinced, but there 20 have engaged in a complex and secretive with the political system. Such cynicism is will be many who can. conspiracy. They are depicted as using the growing, a development that should not be This leaves those cases where denialist peer review process to suppress dissent rather surprising given how politicians feel able to views are being promulgated actively by pow- than fulfil its legitimate role of excluding work take their countries to war on the basis of dubi- erful vested interests. Here, we argue, health that is devoid of evidence or logical thought. ous evidence.21 professionals have a responsibility to con- Use of fake experts: It is rarely difficult to find A second issue, in some countries, is the front the denialists, exposing the tactics they individuals who purport to be experts on some espousal of denialism by an increasingly use and the flaws in their arguments to a wide topic but whose views are entirely inconsistent partisan media, which expends considerable audience. Again, the first step is recognition. with established knowledge. The tobacco energy identifying supposed conspiracies that When a seemingly bizarre story appears in the industry coined the term “Whitecoats” for they then espouse to the general public.22 media that risks undermining public health, those scientists who were willing to advance The third is the growing exploitation of health professionals should ask: “why is this its policies regardless of the growing scientific the first two issues by corporate interests. story appearing now?” Many will, however, evidence on the harms of smoking Although the tobacco industry has been at find this approach uncomfortable because it Selectivity of citation: Any paper, no matter the forefront of such tactics, there are now conflicts with the common tendency to seek how methodologically flawed, that challenges examples from many other sectors, including compromise and avoid conflict. the dominant consensus is promoted the food and drink, asbestos, oil, and alcohol Confronting denialism may also require the extensively by denialists, whereas any minor industries. Such activities received consider- use of less usual methods of communication, weaknesses in papers that support the able official support during the administration such as analogy and narrative. Crucially, it dominant position are highlighted and used to of George W Bush, under whose aegis there demands speed of response. However, health discredit their messages. were widespread attempts to politicise scien- authorities and non-governmental organisa- Creation of impossible expectations of tific research and advice.23 24 tions are rarely able to respond rapidly, espe- research: This may involve corporate bodies cially at weekends when, in our experience, sponsoring methodological workshops that Tackling denialism misleading stories tend to appear in the media. espouse standards in research that are so high So how should scientists respond to denial- Equally, editors of medical journals (with a few as to be unattainable in practice. ism? The first step is to recognise when it is exceptions) often seem unable to appreciate Misrepresentation and logical fallacies: An present. Denialism changes the rules of the the need to counter denialist stories. extreme example of this characteristic is game. Conventional approaches to scientific In this paper we have looked at some of the phenomenon of reductio ad hitlerum, progress—such as hypothesis generation and the most outrageous examples of denialism. in which anything that Hitler supported testing, and argument and counterargu- Yet denialism is often much more subtle, and (especially restrictions on tobacco) is ment—that seek to elicit the underlying truth researchers are far from immune to its effects. tainted by association. Other methods of misrepresentation include using “red no longer apply. There is a wealth of evidence on how reviewers herrings” (deliberate attempts to divert In some cases, nothing can or needs to be find real or imagined flaws in papers whose attention from what is important), “straw done. The persisting belief among many people messages they disagree with while discounting men” (misrepresentation of an opposing that Princess Diana may have been murdered real errors in those they agree with. Perhaps, view so as to make it easier to attack), false by the security services (32% of the British during the Christmas break, we, as reviewers analogies (for example, because both a watch public in one poll),25 26 for example, has ena- and editors, might all take some time out to and the universe are extremely complex, bled some tabloid newspapers to fill many reflect on our own innate cognitive biases as the universe must have been made by some pages and has wasted much police time, but well as how to overcome those of others.29 cosmic watchmaker), and excluded middle has no persisting implications for public policy. Contributors: This paper builds on previous work on fallacies (in which the “correct” answer is In other areas, especially where the views denialism by the authors. Both authors contributed equally presented as one of two extremes, with no reflect longstanding cultural beliefs, it may be to writing it, following a commission from the BMJ. middle way. Thus, passive smoking causes necessary to accept that these views exist and Provenance and peer review: Commissioned; externally either all forms of cancer or none, and as it peer reviewed. adapt messages to take account of them when can be shown not to cause some it must, it is developing policies and practices. Examples Martin McKee professor of European public health, argued, cause none). include the development of health promotion London School of Hygiene and Tropical Medicine, London, UK [email protected] Manufacture of doubt: Denialists highlight campaigns to prevent the spread of HIV27 or to Pascal Diethelm president, OxyRomandie, Geneva, any scientific disagreement (whether real or encourage the uptake of immunisation.28 Such imagined) as evidence that the entire topic is Switzerland campaigns are based on a detailed assessment contested, and argue that it is thus premature of the beliefs that would undermine them if not Cite this as: BMJ 2010;341:c6950 to take action. confronted. For example, early programmes to References are in the version on bmj.com
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Integrative medicine and the point of credulity So called integrative medicine should not be used as a way of smuggling alternative practices into rational medicine by way of lowered standards of critical thinking. Failure to detect an obvious hoax is not an encouraging sign
t is a common, and rarely unsuccessful, suggest that so called integrative medicine is paper to something called “The Jerusalem Con- ploy to change the name of something somehow confined to the alternative world is a ference on Integrative Medicine.” unpleasant in order to give it greater canard. The invitation announced: acceptability. However, changing the name It is sometimes possible to test the status of a of Windscale nuclear plant to Sellafield notion (the terms hypothesis and theory should An International Conference on Integrative Iafter an accident in 1981 made it no less radio- be reserved for ideas that are related to at least Medicine will be held in October 2010 in active, and the new name quickly acquires all some form of evidence) by a process of oppo- Jerusalem. It will be a meeting of professionals in the connotations of the old. sition. This involves testing the status of the the field of medicine from around the world that Increasing concern has been expressed about notion by looking at the limits to which it can will deal with ways to unite the scientific principles the presence of complementary and alternative be pushed.5 Furthermore, there is an excellent of modern medicine with the holistic principles of medicine (CAM) on the NHS. For instance, the tradition of testing research areas of dubious alternative medicine…. The scientific committee House of Commons Science and Technology authenticity by means of a hoax. In 1996, Alan of the convention is still open to accept additional Committee recently reported critically on the Sokal had a paper accepted in a cultural stud- topics to the conference program. evidence base for the use of homoeopathy in the ies journal, in which he parodied postmodern NHS.1 Nationally and internationally, there has philosophy and cultural studies by making a On 1 June 2010, I sent them the following been a move to disguise the nature of CAM by series of exaggerated, wrong, and meaningless invented nonsense: renaming it “integrative medicine.”2 3 Of course, statements about the potential progressive or lib- it is something of an insult to medical practition- eratory epistemology of quantum physics in the I write to ask if you would be interested in a ers to suggest that they do not take into account style of the field.5 This he subsequently described presentation on my recent work on integrative their patients’ individuality, autonomy, and in a book, bluntly called Intellectual Impostures.6 medicine. I am an embryologist by background, views as part of their daily practice. It is certainly In the spirit of Sokal, therefore, I responded to with an extensive publication record, in journals a key tenet of evidence based medicine4 and to a mass circulated email invitation to submit a including Nature and the Proceedings of the Royal CLAUDIABENTLEY
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Society, and have written an award winning text in order to define the best methods of treatment. book on medical embryology. Recently, as a result In the presentation, anonymised case histories, of my developmental studies on human embryos, “testimonies” and positive outcomes will be I have discovered a new version of reflexology, presented. The methodology does not lend itself which identifies a homunculus represented in to randomised double blind controlled trials, for the human body, over the area of the buttocks. obvious reasons. The homunculus is inverted, such that the head is Obviously, the involvement of a sensitive area of
represented in the inferior position, the left buttock the body poses special challenges. Ethical practice LONDON MUSEUM, HISTORY NATURAL THE corresponds to the right hand side of the body, is of significant concern. Informed consent must and the lateral aspect is represented medially. As be obtained from all patients in writing, before with reflexology, the “map” responds to needling, either therapeutic or diagnostic procedures as in acupuncture, and to gentle suction, such as are commenced. Although exposure of cupping. In my studies, responses are stronger and the gluteal region is recommended, of more therapeutic value than those of auricular or procedures can be carried out using conventional reflexology. In some cases, the map draping if this is required in order can be used for diagnostic purposes. to gain patient cooperation. Chaperones or same sex Although I resisted the temptation to draw practitioners are recommended in an analogy with the mappings of phrenology, I the case of female patients. still had it in mind, and the reference to gentle Unfortunately, this novel suction might have been taken by a sceptical paradigm may meet with closed reader to refer to the idea of kissing the point of minds and automatic rejection. Patience credulity. and understanding of “closed” mindsets is The organisers replied on the same day. essential in order to advance this new discovery in a intrinsically ridiculous as in this case. Minimum way commensurate with its importance. standards of common sense should, I think, have Dear Prof. McLachlan *See for example http://dermnetnz.org/ led to a polite but firm rejection—or at least fur- I thank you for your interesting and enriching mail. pathology/blaschko-lines.html. ther inquiry. Alternative medicine is not noted for In order to bring the proposal to the Scientific rigorous inquiry, for research designed to prove Committee I would appreciate it if you could send My initial email and abstract were constructed the null hypothesis, but rather accepts notions me an Abstract of your proposed lecture. And a short C.V. to include appeals to authority, hints of con- on face value. Therefore a face value test is fair. Yours Sincerely spiracy theories, and “scienciness,” but with an I did also, to be honest, feel a little uncomfort- [name redacted] absence of evidence or plausibility. I received this able about it. There was an element of deception The Jerusalem International Conference on from the organisers on 26 July 2010. involved, and academic intercourse generally Integrative Medicine relies, to some degree, on good faith. I sent off Dear Prof. John C. McLachlan, the abstract in a spirit of fun, but then hesitated I replied on the following day: You have sent a proposal to the The (sic) Jerusalem about making it public. I did decline the invita- International Conference on Integrative Medicine. tion (though I have never been to Jerusalem, and ABSTRACT We are happy to inform you that the Scientific would have enjoyed the trip) but I didn’t want to Intensive study of the development of early human Committee has reached its decision and that your cause harms by taking up a conference slot. But embryos indicates that there is a reflexology style paper has been accepted and you will be able to in the end, just as so called gentle teasing may homunculus represented in the human body, present your lecture. The time frame will be 15-20 reveal structures to the anatomist, so a different over the area of the buttocks. This homunculus minutes. Considering the tight schedule, I will kind of gentle teasing may reveal something to corresponds to areas of clonal expansion appreciate if you’ll confirm your participation in the philosopher, and may promote an element of (“Blaschko lines*”), in which compartments of the convention. self awareness in proponents of alternative medi- the body have clear ontological relationships cine, no matter what grand title it is disguised with corresponding areas of the posterior flanks. Unfortunately, I did not believe that I wished under. It provides, at the least, an opportunity for The homunculus is inverted, such that the head to carry the joke so far as to actually attend, reflective practice, which I hope proves of some is represented in the inferior position, the left although part of me was tempted. benefit to us all. buttock corresponds to the right hand side of I fully accept that this is just one instance, Competing interests: None declared the body, and the lateral aspect is represented relating to a particular conference. And con- Provenance and peer review: Not commissioned; not medially. The Blaschko lines mediate energy flows ference abstracts are refereed less stringently externally peer reviewed. to parent areas, and lead to significant responses than full papers. But I also believe that the idea John C McLachlan, professor of medical education, to appropriate stimuli. As with reflexology, the I proposed was intrinsically and self evidently School of Medicine and Health, Durham University, “map” responds to needling, as in acupuncture, ridiculous. Whereas Sokal’s hoax parodied the Stockton-on-Tees TS17 6BH, UK and to gentle suction, such as cupping. Responses incomprehensibility and reductio ad absurdum [email protected] are stronger and of more therapeutic value than of some proponents of cultural studies’ approach Cite this as: BMJ 2010;341:c6979 those of auricular or conventional reflexology. In to natural sciences, this particular hoax parodied some cases, the map can be used for diagnostic the absurdity and credulity of so called integra- bmj.com/archive purposes. In both therapeutic and diagnostic tive medicine. I do not believe that rational medi- ЖЖChristmas 2009: Secret remedies: interventions, a full case history must be taken, cine could have been fooled with something so 100 years on (BMJ 2009; 339:b5432)
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On the impossibility of being expert More scientific papers are being published than ever before.Alan G Fraser and Frank D Dunstan call for that new strategies to deal with this avalanche of information
very doctor has an ethical duty tomography (CT), and coronary arteriography, as which time at least 82 142 more papers would have to keep up to date. Is this just get well as cardiovascular ultrasound (strategies 5-6, been added, accounting for another eight years ting more difficult or has it already table). and 78 days. Before our recruit could catch up become impossible? Since Alvin All searches were performed for each year from and start to read new manuscripts published the Toffler coined the phrase “inform 1966 (the year before ultrasonics was introduced same day, he or she would—if still alive and even Eation overload” in 1970,1 the growth of sci as a search term in remotely interested— 10 entific and medical information has been PubMed; echocardi Echocardiograph* have read 408 049 Echocardiography MeSH inexorable. There are now 25 400 journals in ography was added in 8 papers and devoted (or Echocardiography Majr science, technology, and medicine, and their 1973) to 2009. Trends Echocardiography Majr CTs served a sentence of) 6 number is increasing by 3.5% a year2; in 2009, in papers on echocar 40 years and 295 days. they published 1.5 million articles.2 PubMed diography were mod 4 On the positive side,
now cites more than 20 million papers. elled; a good fit—from (000s) year per published s 2 our recruit would fin
One response of the medical profession to the a cubic model contain aper ish just in time to retire.
P 0 increasing scientific basis and clinical capacity of ing time, the square 1966 1974 1982 1990 1998 2006 2014 Reading only the medicine has been to increase subspecialisation. of time, and the cube Year major studies would This may restrict the breadth of knowledge of the of time—was used to Fig 1 | Trends in numbers of papers listed each need more than four ultraspecialist, but can such subspecialists main predict the numbers of year in PubMed, according to search strategies 1-4 years for strategy 3 and tain their depth of expertise? Taking one medical publications to the end in table. The numbers to the right of the vertical line, more than five years subspecialty as an example, we have examined of 2010 and annually after 2009, are projected totals. MeSH=medical for strategy 6. Alterna the gap between information and human capac to 2015. subject heading, Majr=as a main topic; tively, if only one year ity, and we explore the implications for any doctor CTs=controlled clinical trials was allocated for study, who wants to practise evidence based medicine. Results then for strategy 3 our The table shows the publications retrieved by each recruit would need to read 95 papers every single Methods search, along with totals for the last full calendar day. If our recruit kept to the European Working We searched the database of the US National year. Figures 1 and 2 show annual totals to 2009 Time Directive, he or she would have to read 138 Library of Medicine (PubMed) on 12 September and predictions from 2010 until 2015. papers a day, or for strategy 6, 162 papers a day at 2010 for references relating to diagnostic imaging Search 5 without the cardiovascular system a rate of one every three minutes. in cardiology. The table shows the search terms gave 700 011 citations. A search for “diagnostic To keep up to date, the cardiac imaging special used. imaging” [Mesh] and “cardiovascular system” ist needs to read 30 papers a week on echocardio Citations with any reference to echocardio [Mesh] gave 195 106 papers, or 159 661 if lim graphy or 43 a week on multimodality imaging. If graphy (the mainstay of diagnosis) were searched ited to human studies, core clinical journals, and limited to one paper every working day (estimated first, and then the strategy was narrowed to Medline. total 250 a year), then the chance that he or she echocardiography as a main topic and restricted To estimate the time that it might take a new will read any particular paper is 1 in 8.9. The to controlled clinical trials (strategies 1-4; table). entrant to the subspecialty to read all the previ chance that a colleague on the opposite side of the It is recommended that junior colleagues should ous literature, we assumed that he or she could world will read that same paper in the same year be trained in several imaging modalities,3 and so read five papers an hour (one every 10 minutes, is 1 in 79. If each reads a random selection of 250 we performed further searches for the concept followed by a break of 10 minutes) for eight hours papers a year, then the median number that both of “multimodality imaging” in cardiology. This a day, five days a week, and 50 weeks a year; this will read can be estimated at 28 (range 16-40) or included single photon emission computed tomo gives a capacity of 10 000 papers in one year. 1.3% of the total. graphy (SPECT), positron emission tomography Reading all papers referring to echocardiography A search strategy restricted to evidence on out (PET), magnetic resonance imaging, computed (search 1) would take 11 years and 124 days, by comes would not work for this subspecialty. The
Search strategies for identifying articles on diagnostic imaging in cardiology Total no of papers from 1966 to Papers published Strategy Question September 2010 in 2009 1 All papers that include any reference to echocardiography 113 976 7207 2 All papers cited with echocardiography as medical subject heading 84 689 4672 3 All papers with echocardiography as a main topic 34 577 1558 4 Papers with echocardiography as a main topic, restricted to human controlled trials 457 23 5 All papers referring to the cardiovascular system and any one of multiple imaging modalities cited as a medical subject 109 604 7083 heading; referred to in text as any “multimodality imaging” 6 All papers referring to the cardiovascular system or diagnosis of cardiovascular disease and any one of multiple 40 496 2226 imaging modalities, if cited as a main topic and limited to humans; referred to in text as major “multimodality imaging”
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average number of controlled clinical trials that were published during the decade 2000-9 (search 4) was 26 each year. This number is not increas ing, and it represents only 2% of the publications with echocardiography as a main topic (search 3) or 0.5% of all papers referring to echocardiography (search 1) during the same period.
Discussion The gap between what we can learn and what is known is increasing all the time. We now know less and less about more and more, so being expert means knowing and publicly acknowl edging the limits of your ignorance. Our analysis of one subspecialty showed no evidence whatso ever that the problem is abating, and remarkably similar patterns were reported recently for clinical trials and systematic reviews.4 Keeping up with the literature has already become a Sisyphean task. We are even engulfed by information over ble. Reading the literature has become a collective life,18 but only 2.4% of diagnostic recommenda load about “information overload”5; searching rather than an individual pursuit, and each of us tions in the guidelines from the American Heart this term on Google gives about 980 000 hits. must change our behaviour to reflect this. Association and the American College of Cardio We did assume that all papers have equal Medical students and doctors in training can logy are supported by this level of evidence.19 value, which is clearly untrue, but we did not be taught to search databases effectively.15 Doc It is time for the profession to be more imagina allow any time in our calculations for obtaining tors can use new information technologies to tive. How can we reduce the number and increase papers, and we ignored the projected increases. gain prompt and efficient access via the internet the quality of publications?20 Can we remove the Impact factors are concentrated in a few jour to the most relevant new data for their specialty.16 responsibility of all researchers to publish all nals,6 and citation errors are common,7 so try The Cochrane Collaboration is admirable, but its their results? Could they contribute instead to ing to use either to select what to read would be programme of systematic reviews is not compre wikis? Can we construct open access internet unreliable for a topic such as medical imaging. hensive, so all academic institutions and medi resources that allow data mining? Only initiatives Misconceptions are promulgated when authors cal professional associations should contribute to such as these will overcome our worrying find do not check primary sources,8 9 and even when collective efforts to summarise medical evidence ing that colleagues in the same medical discipline findings are contradicted by randomised control and build trustworthy, interactive repositories may inhabit intellectual worlds with little overlap. led trials.10 Systematic reviews are not all being of knowledge on the internet. Authors of clini Happy reading! kept up to date.11 Thus, delegating the selection of cal guidelines have a particular responsibility to Contributors: AGF conceived the study, performed the literature reading material to others might be unrewarding. ensure that their recommendations are based on searches, and drafted the manuscript. FDD performed the modelling and revised the manuscript. AGF is guarantor. If anything, we probably underestimated calls rigorous and re-testable meta-analyses of ran Funding: None received. on the doctor’s time domised controlled 8 Competing interests: The authors have completed the Unified for reading. Accurate Any “multimodality imaging” trials, health technol Competing Interest form at www.icmje.org/coi_disclosure.pdf diagnosis is a prerequi Major “multimodality imaging” ogy assessments, and (available on request from the corresponding author) and declare 6 site for evidence based systematic reviews. no support from any organisation for the submitted work; no financial relationships with any organisations that might have medicine, but experts 4 Appropriate resources an interest in the submitted work in the previous three years; in multimodality imag must be allocated FDD does occasional epidemiological consultancy for a law firm 2 (Jacob, Medinger, & Finnegan) and has grants for unrelated work.
ing should also know (000s) year per published s for researchers and AGF has no other relationships or activities that could appear to
something about clini aper experienced senior have influenced the submitted work. P 0 cal and other aspects of 1966 1974 1982 1990 1998 2006 colleagues to dedicate Provenance and peer review: Not commissioned; externally their specialty. Year time to these activi peer reviewed. Faced by the deluge Fig 2 | Trends in numbers of papers cited each ties. More could also For references and search terms for each strategy see bmj.com of data, it is tempting to year in PubMed, according to search strategies 5 be done to develop Alan G Fraser, reader in cardiology, Wales Heart be nihilistic. After all, and 6 in the table decision support Research Institute, School of Medicine, Cardiff being ignorant of 100% tools.17 University, Cardiff CF14 4XN, UK [email protected] of the literature in your field is not significantly In fields such as diagnostic imaging the Frank D Dunstan, professor of medical statistics, different from being ignorant of “only” 98%. On plethora of publications hides the fact that we Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK the other hand, reading even 2% is more than still lack sufficient evidence for rational practice. reading nothing at all. The average specialist The small proportion of papers that were cited EDITORIAL by Annas reads 322 papers a year,14 and a few brave, excep as controlled clinical trials (search 4) reinforces Cite this as: BMJ 2010;341:c6815 tional, and overcommitted people might accept this notion. The best way to assess any diagnostic the challenge of reading more. For most ordinary strategy is a controlled trial in which investiga bmj.com/blogs mortals, this is impossible, and for clinicians who tors randomise patients to diagnostic strategies ЖЖRead Annabel Bentley’s blog about are not also researchers it may no longer be sensi and measure mortality, morbidity, and quality of information overload at bmj.com/blogs
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A dose by any other name would not sell as sweet Inventors of drug names suddenly stood the alphabet on its head. Why did z and x become so attractive in the attempt to infl uence prescribers, asks Rob Stepney
f you leaf through the June issue of Generic names of drugs listed in the article More likely, though, is that use of these letters the British Journal of Cardiology you will see Brand name Generic name relates to the imperative to make a brand name advertisements for Zocor, Xenical, and Cozaar Zocor Simvastatin highly visible in a crowd. Refl ecting their infre- before you reach a brand name that does not Xenical Orlistat quent occurrence in English words, x and z count Cozaar Losartan contain a prominent x or z (and that brand Viagra Sildenafil for and points in Scrabble, the highest val- Iis Viagra). In an issue of Hospital Doctor from ues (along with j and q) in the game. So names Celebrex Celecoxib the same month ( June), adverts for Celebrex, Topamax Topiramate that contain them are likely to seem special and Topamax, Flomax, Vioxx, Zispin, Zyprexa, Flomax Tamsulosin be memorable. “If you meet them in running Oxis, Efexor, and Fosamax outnumber those Vioxx Rofecoxib text, they stand out,” is the way one industry for brands not containing letters from the tail Zispin Mirtazapine insider explained. Generally, they are also easy Zyprexa Olanzapine end of the alphabet. Examination of the British Oxis Formoterol to pronounce. National Formulary ( BNF ) from to Efexor Venlafaxine That is an old insight in the wider fi eld of mar- confi rms that z and x suddenly achieved remark- Fosamax Alendronic acid keting. But in pharmaceuticals z did not really able and previously unexplained popularity in Zyloric Allopurinol take off as a brand initial until after , with the branding of drugs. Zinacef Cefuroxime the number of drugs beginning with the letter ris- Of products added to the BNF between Zovirax Aciclovir ing steeply from to in (fi gure). And the Zantac Ranitidine and , more than a fi fth had names Zirtek Cetirizine widespread use of x (often also pronounced as that began with z or x or contained a prominent Zoladex Goserelin “zuh”) is later still. Something additional started x or z within them. In , only branded Zithromax Azithromycin the bandwagon rolling. drugs began with one of these letters. Over the Zoton Lansoprazole next two decades, the number of brands begin- Prozac Fluoxetine Z and x spell Zuxess Zoloft Sertraline ning with a z increased by more than % (to Whatever the initial thinking that lay behind Nexium Esomeprazole ) and those beginning with an x increased by Plavix Clopidogrel the use of the letter, the people responsible for % (to ). In the same period, the overall Xanax Alprazolam marketing drugs spotted in the s that an content of the BNF grew by only %. Xylocard Lidocaine unusually large number of z brands had already Why did these letters suddenly become so Xyloproct Lidocaine achieved blockbuster status or were well on the attractive to companies trying to persuade doc- Xalacom Latanoprost way towards it. Xenazine Tetrabenazine tors to prescribe their drugs? In linguistics, the Both Wellcome and Glaxo—then unrelated Xyzal Levocetirizine “zuh” sound is described as a voiced fricative. Xeloda Capecitabine companies—showed an early liking for z and The “fricative” element refers to the fact that air- Xatral Alfuzosin enjoyed conspicuous success. Wellcome had fl ow directed over the tongue becomes turbulent Zestril Lisinopril introduced Zyloric for gout in and Glaxo the when passing the sharp edges of the teeth, while Innovace Enalapril intravenous antibiotic Zinacef in ¢. But it was the “voiced” aspect refl ects the vibration of the Tritace Ramipril in that both companies hit the jackpot with Pulmicort Budesonide vocal cords. But there is nothing magical in the Wellcome’s launch of the antiherpes drug Zovirax Flixonase Fluticasone sound itself. One suggestion for the popularity of Taxol Paclitaxel and Glaxo’s launch of the H receptor antagonist z is that it works well in the Middle East, which Oncovin Vincristine Zantac. In , Zovirax became the world’s fi rst was becoming an increasingly important mar- Herceptin Trastuzumab billion dollar drug; and Zantac was the world’s ket for drug com- Erbitux Cetuximab best selling drug by . In its fi rst years, it panies. This Aprovel Irbesartan was used to treat more than million people. The antihistamine Zirtek and the fi rst agonist has a superfi cial plausibility: think of how of luteinising hormone releasing hormone Zola- Arab scientists launched astronomy dex (both introduced in ), the antibiotic with the terms zenith and azi- Zithromax (), and the proton pump inhibi- muth. X, though representing tor Zoton () all became highly successful; the unknown for centuries, and Prozac (¢) made such an impression has been famously associated that its name branded a generation. In , with medical advance since three of the world’s top drugs (each grossing x rays. So this too would between and billion dollars annually) were have appeal. Zocor, Zyprexa, and Zoloft. Also among the top
1316 BMJ | 1825 DECEMBER 2010 | VOLUME 341 READING BETWEEN THE LINES
Certain drug names have always alluded
s 70 Z X helpfully to the chemical class of the 60 agent (as in Innovace, Tritace), its target
No of drug 50 organ (Pulmicort, Flixonase), the plant 40 species from which the prototype drugs 30 were derived (Taxol, Oncovin) or the drug’s 20 molecular target (Herceptin, Erbitux). Otherwise, 10 when they are sticking to the rules, those invent- 0 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 ing brand names for drugs have little scope to Antonio Zanussi. But there are many examples Year play with anything but the sound of letters, and of brand name coinage that are as contrived as to some extent the appearance of the word. This those used to market drugs and precede them. For Fig 1 | Number of drugs with a brand name beginning with z or x listed in March edition of BNF is presumably why we have the odd repetitions the best part of a century, marketing has gone for for each year. New formulations of existing brands seen in Vioxx and Cozaar) If any alphabetical certain arbitrary syllables like “ex”, “ax” or “ox.” and zinc related compounds have been excluded quirk seems to be working well, there must be a These are stuck on to a meaningful word, as in strong temptation to follow suit. Timex, Artex, or Tampax, or a meaningful word Sometimes, though, the rules get bent or misspelt, as in Kleenex (introduced in ). ten drugs that year were two with the X factor: broken. Aprovel manages to convey the idea of Xerox, which became a trademark in ( Nexium and Plavix. endorsement and Celebrex and Zestril a clear years before the double x stratagem became The widespread use of x at the start of a brand joie de vivre. Indeed, the contrasting stories of popular for drugs) is an acknowledged classic. is a more recent ploy in drug marketing, seem- the two brands of lisinopril, both launched in the That said, the use of x and z in drug brands ingly designed to achieve the sound of a z while late s, would make an interesting case study. suddenly became extraordinarily prevalent. I sug- looking diff erent. In the BNF there are a few ICI Pharmaceuticals called its lisinopril Zestril. gest that this phenomenon arose because of the (notably Xanax, Xylocard, and Xyloproct). The Its competitors marketed the same molecule as fast rate at which new products were being intro- big year for brand introductions with this feature Carace. Whereas Zestril became one of the medi- duced, the fact that the diff erence between many did not come until , but by there were cal world’s most successful brands, Carace sank “me too” drugs was more apparent than real, the more than a dozen including Xalacom, Xenazine, pretty much without trace. Was the diff erence due immense rewards that were seen to accrue from Xyzal (successor to Zirtek), Xeloda, and Xatral. to the z, the zest, or both? innovative marketing, and the fact that the ploys People who work in branding speak of it as a Product naming, of course, is an art that available for use in the naming of drugs are so means of making a product more than it actu- extends across all commercial activity; and z restricted. ally is. In many areas, this is achieved by add- and x have played an important role elsewhere. I thank the staff of the BMA library for their help in enabling ing persuasive emotional (and some would say Of the cars currently listed as fastest in the me to consult copies of the British National Formulary from 1985 to 2005. irrational) content. If you buy a car named after world (all capable of - mph in under four Competing interests: None declared an animal famed for its exhilarating speed and seconds), four—including the Ferrari Enzo and Provenance and peer review: Not commissioned; elegance, that is what you associate with the vehi- the Jaguar XJ—have a z or x in their names. externally peer reviewed. cle. But in the tightly regulated world of pharma- For some brands, the prominence of a key letter Rob Stepney, freelance medical and science writer , ceuticals, drug names are supposed to be devoid is fortuitous: Zanussi, the white goods manufac- Charlbury, Oxfordshire, UK of what the Medicines Control Agency used to call turer, apparently derived its name from the early [email protected] “unsubstantiable benefi cial” connotations. th century blacksmith and stove manufacturer Cite this as: BMJ 2010;341:c6895
A Christmas tree cataract
A 73 year old woman referred for cataract surgery had on examination a right Christmas tree cataract (fi g 1A). Highly refl ective, iridescent, polychromatic crystals were noted within the lens. Their colours varied according to the angle of the incident light, (fi g 1B, C). It has been postulated that Christmas tree cataracts result from the accelerated breakdown of membrane associated proteins. The peptides and amino acids accumulate in the lumen of the reticular meshwork, and cystine is concentrated beyond the level of crystallisation, giving rise to growing crystals. Ebube E Obi specialist trainee, ophthalmology , Gartnavel General Hospital, Glasgow G12 0YN, UK [email protected] C Weir consultant ophthalmologist , Gartnavel General Hospital, Glasgow G12 0YN, UK Cite this as: BMJ 2010;341:c6644
BMJ | 1825 DECEMBER 2010 | VOLUME 341 1317 CHRISTMAS 2010: READING BETWEEN THE LINESREADING BETWEEN THE LINES
Pie sharing in complex clinical collaborations: a piece of cake? The Little Red Hen learns some important new lessons in K T Buddingh’s cautionary, but entirely fictitious tale
Little Red Hen lived in her mentors to share the news. a university hospital “Welcome everyone,” said where she took care the Cow. “I would like to present of the sick animals in the outstanding result of our co- the different wards. operation.” She then took half of AShe did this under the oversee- the pie and left the room. The Pig ing eye of her wise and learned was next. “Excellent work, Little mentors. There was the Cow, who Red Hen.” He cut himself a size- had a degree from a prestigious able piece of the pie and left the overseas university. There was room. Then the Sheep stepped the Pig, who had led mergers of forward. “What a feat of culinary several high standing hospitals craftsmanship did we achieve! in the country. And there was the Congratulations on your first Sheep, who had an outstanding pie.” He cut a small piece of the treatment record with almost no pie, and took the rest. animal morbidity and mortality. The Little Red Hen sat in the One day the Little Red Hen conference room and stared thought: “Why don’t I see if I at the small piece of pie that can use my scarce free hours remained. Although happy to at the end of the day and make have baked her first pie and to an excellent pie. Not only will have contributed to the gastro- this pie add to the gastronomic nomic knowledge, she was left knowledge, it could be that the with an inexplicable feeling sick animals will benefit from of disappointment. It did take this pie in the long run.” quite some time before the Lit- So the Little Red Hen ran her tle Red Hen attempted to bake idea past her mentors. another pie. “Great idea,” said the Cow. “I Disclaimer: This tale is based upon will supply the milk and the but- FLORENCEWHITWILLIAMS/THE LITTLE REDHEN coffee table stories and a compilation of reported experiences in the academic ter. Of course, I would like a piece of the pie want you to make sure that my piece of the pie hospital at no specific place. Any names, characters, places, when it is baked.” is larger than that of the Sheep.” and incidents are either the product of the tale or are used “Excellent,” said the Pig. “I happen to know The Little Red Hen continued to the Pig. fictitiously. Any resemblance to actual events or locales or persons, living or dead, is entirely coincidental. the editor of a prestigious cook book. I expect “Hold on,” said the Pig. “I have submitted a Contributors: KTB came up with the idea and wrote the a piece of the pie once it is finished.” grant application for possibly an even bigger first draft. LMAC gathered opinions and experiences from “Good thinking,” said the Sheep. “My labo- pie, so I cannot actively co-operate any longer colleagues in the university hospital and contributed ratory will provide the necessary utensils. Just on the current pie. However, if you do bake it, significantly to the description of the characters in the tale. GMvD ran a spell check on the document and demanded make sure I get a share of the pie.” don’t forget to give me a piece.” that, as senior investigator, he received a prime author The Little Red Hen wasted no time. Every The Little Red Hen then visited the Sheep. position. After negotiations, he edited the paper for style, day, after taking care of the sick animals she The Sheep was abroad for a conference on contributed to the plot of the tale, and settled for the middle author position. spent the last few hours of daylight planning animal wellbeing with an extended post- Competing interests: None declared. the pie. She took classes in pie making, wrote conference tour, and his laboratory had received Provenance and peer review: Not commissioned, not pie making protocols, and even obtained no instructions to provide any utensils. externally peer reviewed. approval from the institutional pie review The Little Red Hen went to work. She tested K T Buddingh, research physician board. And after a few months, all prepara- her own recipes, made do with her limited [email protected] tions were in place. utensils, and fluttered between different G M van Dam surgeon, L M A Crane research The Little Red Hen first went to the Cow and departments to keep everybody satisfied. physician, Department of Surgery, University Medical asked for the milk and the butter. “I have the Finally, after many long hours and many failed Centre Groningen, Post Box 30.001, 9700 RB milk and the butter for you. However, I heard pies, an acceptable pie came out of the oven. Groningen, Netherlands that the Sheep will also have a part of the pie. I Overjoyed, the Little Red Hen called together Cite this as: BMJ 2010;341:c6641
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