The movement towards evidence-based medicine (EBM) is gaining attention and momentum. It is really quite a simple concept: EBM is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al. 1996, p. 71), just as its name suggests. Efforts are being made to translate research into practice (e.g. the tagline of the British Medical Journal *applause* is helping doctors make better decisions), but this is not without controversy and pitfalls (well that escalated quickly).
The above mentioned definition of EBM is by no means the only definition of EBM, but is one that reveals, in my opinion, its greatest weaknesses: it suggests that practitioners be informed by current best evidence. Current evidence? Then how to proceed in the absence of evidence? Or rather, was there an absence of evidence? How could we know? And why might there be such an absence of evidence?
Take the example of oseltamivir, commonly known as Tamiflu. The time is 2003 and three published study suggests that this drug is effective in reducing complications associated with influenza. At roughly the same time, SARS, avian flu, swine flu etc. raged across the globe. Governments panicked and poured billions into stockpiling this drug. Turns out, oseltamivir isn’t really the miracle drug that everybody thinks it is: a 2009 meta-analysis reveals that is really no evidence to suggest that oseltamivir is effective in any way. We were literally blinded from the entire truth: there was not just three but at least eight other RTCs conducted on oseltamivir, only three ended up being published while the others were locked up by Roche (big phrama) (Ebell et al. 2013). Why were they not published? If you guessed because those studies didn’t find that oseltamivir was a “good drug”, good for you!
Publication bias, or positive-outcome bias, is an issue. This is something that happens beyond clinical trials, even without the “forces of big corporation”. Let’s face it, nobody likes to publish negative results (Fanelli 2012).
My evil twin recently experienced something similar. She has been trying to publish one of her papers since July 2011. Said paper, reporting a negative result, was rejected by four journals, and she kept getting comments like:
So you didn’t find anything. You learned nothing. Then what are we trying to publish here? (paraphrased)
Other reasons for not liking negative results?
You must have done your analysis wrong.
Your experiment was poorly designed.
Your need a more robust question. (whatever that means)
Negative results appear to mean no impact, and this is very problematic. What really matter should be scientific rigor in the design of the study and not the outcome. Every single study, regardless of the outcome, should be scrutinized in the same way. Studies that report positive results could be flawed as well, and those that report negative outcome really doesn’t automatically mean that something is wrong. A negative outcome is an outcome, and it is nice to know that.
In response to this, there are now journals that are dedicated to publishing negative results (as well as replicated studies, which is a great topic for another post another day). The Journal of Negative Results (appropriately named) is one of them. I particularly like this quote from the journal’s home page:
“The primary intention of Journal of Negative Results is to provide an online-medium to publish peer-reviewed, sound scientific work in ecology and evolutionary biology that is scientifically rigorous but does not rely upon arbitrary significance thresholds to support conclusion”
In ancient India, the great mathematician Muhammad ibn Mūsā al-Khwārizmī made one of the greatest breakthroughs in math by acknowledging that the number zero could mean something (more preciously, that 0 has a place on the number line between +1 and -1). Looking back today, this discovery isn’t exactly groundbreaking, but if not for this we would not have algebra today (good news?!) (Barrow, 2001).
Realizing that nothing could mean something, pursuing and revealing those nothings, might very well lead to our next genuine breakthrough in biomedical practices and research.
Barrow, J. (2001). The Book of Nothing. Random House: London.
Ebell, M., Call, M. & Shinholser, J. (2013). Effectiveness of oseltamivir in adults, a meta-analysis of published and unpublished clinical trials. Family Practice, 30, 125-133
Fanelli, D. (2012). Negative results are disappearing from most disciplines and countries. Scientometrics, 90, 891-904
Sackett, D., Rosenberg, W., Muir Gray, J., Haynes, B., Richardson, W. (1996). Evidence based medicine: what it is and what it isn’t: it’s about integrating individual clinical expertise and the best external evidence. British Medical Journal, 312, 71-72
As the population of Earth quietly soared passed 7 billion recently, a few more people bumped shoulders and came to appreciate the finite nature of this magnificent planet. Perhaps more interestingly, a few more lifted their gaze from what they had always perceived as reality and looked up for the first time to realize that their view of the world, their paradigm, is but one perspective in a sea of possibilities. And that no matter how much they wanted to hold onto the idea that their paradigm was the ‘right’ one, they could not help but acknowledge the possibility that it was not, nor the idea that perhaps the notion of ‘right’ was a complete fallacy. And finally, that uncertainty is ok. It is my belief, that as our world grows smaller with every newborn child (and every activated cellphone) that more people will come to see the world as the rich tapestry of worldviews that it is. In academia, I believe that the increasing use of the concepts of interdisciplinarity and transdisciplinarity are a reflection of this much larger phenomenon that is unfolding all around us as a result of a rapidly changing world (Refer to an article by Choi and Pak (2006) for concise definitions of these terms). While academics might be tempted to pat themselves on the back for having come to appreciate the value of these integrated approaches to research, it is the tardiness of their arrival that worries me.
As an interdisciplinary researcher myself, I am experiencing firsthand just how little communication occurs between researchers of the various disciplines that are approaching inter-related phenomena; each one from a different angle and through a different lens. Some see the intricacies at the atomic level, others on the social or economic level and yet others on the ecological level, embedding the entire story into the fabric of the living and non-living. Only now are we beginning to realize that we are often all looking at the same thing and that in appreciating the entire spectrum of perspectives that exist, we can get a most comprehensive view of reality. Huby and Adams (2009) recognize that while we appreciate this as the ideal, so far we have largely failed at actually putting it into practice.
One might suspect that academics would have recognized the need for an integrative approach years, if not centuries, ago and surely that by now we would have many success stories from which we could draw upon as examples. In my view, aboriginal peoples of the world had been practicing transdisciplinary ways of life for millennia before Western science arose. And now it has taken centuries for Western science to come to realize that while specialization can put a human on the moon, it falls far short of offering the sort of integrated perspective we require if we are to overcome the complex challenges we now face as a species. Certainly we are spending a great deal of energy on trying to understand these new concepts, and even so, we struggle to agree on a definition of interdisciplinarity just within the health sector (Aboelela et al., 2006), let alone one for its abstract cousin transdisciplinarity.
Because we as academics have been so late in the game in acknowledging the necessity of these holistic approaches, while cultural neuroscientists investigate potential sociocultural and biological interactions (Chiao, 2009) to explain our delay, I would suggest that we agree to disagree on the specifics of their definitions and begin getting our hands dirty actually applying whatever it is we think they mean to us. One thing I think we can agree on is that they show notable potential for tackling some of today’s most complex challenges. Perhaps by its very nature, the beast of transdisciplinarity is not one that can be caged, defined and filed away but one that deserves to be left alone in the wild to continually confuse, wonder and inspire us as we work towards our individual and collective goals. I have an ironic image in my head that I hope does not manifest itself, one of a world that is going up in flames, so to speak, while the greatest thinkers of our time focus their energy on trying to reach a consensus on a definition of an abstract term that they struggle to conform to their worldviews; a term that seeks to describe the very process that would have saved the world from disaster, had it actually been applied.
Aboelela, S., Larson, E., Bakken, S., Carrasquillo, O., Formicola, A., Glied, S., Haas, J. & Gebbie, K. (2007). Defining interdisciplinary research: Conclusions from a critical review of the literature. Health Services Research, 42; 329-346.
Chiao, J. (2009). Cultural neuroscience: a once and future discipline. Progress in Brain Research, 178; 287-304.
Choi, B. & Pak., A. (2006). Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med, 29; 351-364.
Huby, M. & Adams, R. (2009). Interdisciplinarity and participatory approaches to environmental health. Environ Geochem Health, 31; 219-226.
After watching a performance of Sci-Fi Double Feature–a mash-up of live video performance and puppet theatre– an enthusiastic patron asked the creators of the production: “How did you come up with this brilliant piece of work?” They explained that their artistic differences could have hindered their collaboration, but instead synergized their talents pushing them beyond their comfort zones. Edward Westerhuis, the animator/filmmaker, stated he learned from his partner’s improvisation skills, mainly by saying “yes” to any idea and playing with it until it led to something new. He also stated that saying “no” to an idea hinders the process, and is much more defensive and restrictive. It made me think, could this approach work for multi-inter-trans-disciplinary research teams with disparate “epistemic cultures” (Knorr-Cetina 1999)?
Tina Fey, a known improvisation comedian states with her line of work you need to contribute by being open-minded and non-judgmental, always with the intention of saying “yes and” and with the goal of being part of the solution (2011: 85-85). Paul Farmer a clinician-anthropologist states that complex life or death problems, he terms general problems, are commonly punctuated by, “this can’t be done” (2005b). Like Fey, Farmer asserts that it’s better to say “yes, and” to continue the conversation so that originality, creativity, and innovation can flourish (2005b).
Yet, Farmer is realistic and asserts that innovation and progress require a change in the way disciplines collaborate (Farmer 2005a). I whole heartily agree, as being a Master of Science candidate in an interdisciplinary faculty has allowed me to preview challenges faced in multi-inter-trans-disciplinary contexts. As “research is essentially knowledge production” (Hall et al 2006:766), it would seem one’s epistemology, value judgments, and disciplinary allegiance –read as inter-personal barriers –are obvious places to begin transforming disciplinary work (LeLe and Norgaard 2005). However, inter-personal barriers are only half of the equation (LeLe and Norgaard 2005). For example, the academy is set up to maintain boundaries through granting agencies (Albert et al 2009; Hall et al 2006; Lamont 2009), academic appointments, publication processes, professional scopes of practice, regulatory bodies, professional associations, and medical and research hierarchies (Hall et al 2006). Thus, true health science multi-inter-trans-disciplinary collaboration requires changes in disciplines relational understandings as well as transforming systemic structural level constraints (LeLe and Norgaard 2005).
Sci-Fi Double Feature may seem an inept example for health sciences researchers endeavoring to deal with general problems, but I disagree. These artist-practitioners have come from different disciplines with different epistemologies, value systems, languages, theories and skill sets, yet they were able to collaborate to create an innovative production that pushes the boundaries of video and theatre. Paul Farmer and his organization, Partners in Health, did the same. Through advocacy and persistent innovative thinking, he not only continued the conversation, but changed it for many individuals who believed that HIV medications were not “cost-effective” for resource-poor countries (Farmer 2005ab). We should be like the Sci-Fi creators, Paul Farmer, and Tina Fey and respectfully think flexibly by saying, “yes, and.”
Albert, Mathieu with Suzanne Laberge and Brian D. Hodges
2009 Boundary-Work in the Health Research Field: Biomedical and Clinician Scientists’ Perceptions of Social Science Research
2005a Pathologies of Power: Health, Human Rights, and the New War on the Poor. Los Angeles: University of California.
2005b Pathologies of Power: Rethinking Health and Human Rights in the Global Era. 56:52 min. Calvin College. January 10. http://www.calvin.edu/january/2005/farmer.htm, accessed February 4, 2014.
Fidler, Brian and Edward Westerhuis
2014 Sci-Fi Double Feature. http://www.ramshackletheatre.ca/shows/sci-fi-double-feature/, accessed February 4, 2014.
2011 Bossypants. New York: Little, Brown and Company.
Hall, Judith with Lesley Bainbridge, Alison Cribb, Jane Drummond, Carlton Gyles, T. Philip Hicks, Carol McWilliam, Barbara Peterson, Pamela Ratner, Elizabeth Skarakis-Doyle, and Patty Solomon.
2006 A Meeting of Minds: Interdisciplinary Research in the Health Sciences in Canada. Canadian Medical Association Journal 175(7): 763-771.
Knorr Cetina, K
1999 Epistemic Cultures: How the Sciences Make Knowledge. Cambridge, MA: Harvard University.
2009 How Professors Think : Inside the Curious World of Academic Judgment. Pp. 53-106. Harvard University Press: Cambridge, MA.
LeLe, Sharachchandra and Richard B. Norgaard
2005 Practicing Interdisciplinarity. BioScience, 55(11): 967-975.
“Philosophers have hitherto only interpreted the world in various ways; the point is to change it.”
Karl Marx, Theses on Feuerbach, 1845
“The irrationalities of a scientifically sophisticated world come not from failures of intelligence but from the persistence of capitalism, which as a by-product also aborts human intelligence.”
Richard Levins and Richard Lewontin, The Dialectical Biologist
Recently I started graduate school after several years working as a midwife in Vancouver and rural Philippines with Community-Based Health Programs. And, yup, I’m definitely a ‘red’. Prior to grad school my research experience stemmed from my pre-midwifery years as a community organizer, activist, and participatory action researcher for anti-poverty, feminist, and environmental justice organizations. During those years I had a handful of interactions with academic researchers; interactions fraught with tension over world views, priorities, and the commodification of research for professional advancement. Yet, during my work as a midwife I faced questions I wanted to explore; graduate school allowed me to carve out time to address challenges facing Registered Midwifery.
Reading Lélé and Norgaard’s “Practicing Interdisciplinarity” (2005) resonated for me as they discuss how world views, values, and theories shape supposedly value-neutral scientific research. My orientation towards social justice, human rights, and reciprocity fundamentally shape my research on the prenatal care experiences of poor and marginalized women. My love of dialectical materialism, a profoundly trans-disciplinary method of understanding complex social and ecological phenomena, helps me grasp the social, political, institutional and economic relations which shape the design and provision of medical care in modern society. The closest (not openly Marxist) ‘fit’ with dialectical materialism I have read thus far in the scientific literature comes is Nancy Krieger’s eco-social model (eg: 2012). My feminist standpoint necessarily allies me with the women I care for, am with as midwife, and challenges me to break down the false dichotomies of experience and ideas (Oakley, 1998). Our economic and social position in society shapes our perspective on the world. The concepts of research evidence as ‘proof’ and the confines of discipline have been challenging for me, and brings up the tensions I have previously had with academics, that in order to be rigorous, knowledge and ideas must be crystallized through the lens the Western academic project.
CP Snow’s seminal 1959 lecture “The Two Cultures and the Scientific Revolution” challenges the culture of Western intellectual life, or rather the ‘two cultures’ of natural sciences and the humanities, to collaborate to tackle the growing chasm of underdevelopment. CP Snow calls on the ‘two cultures’ to unite in the grand project of exporting the Western scientific revolution and its capital, scholars, scientists, systems of education, and colonial gaze to the (forcibly) underdeveloped world. He poses capitalism as the correct path forward and the neo-colonial project the goal. CP Snow was a Baron, a peer in the House of Lords, and in my opinion espoused the world views of the European bourgeoisie who had flourished precisely because of the colonial plunder of developing nations and the mass export of surplus labour to the settler states in the Americas. In his context, the shift from colonialism to neo-colonialism is strategic. But as Richard Levins states in Living the 11th Thesis, “…there was another view, that each society creates its own ways of relating to the rest of nature, its own pattern of land use, its own appropriate technology, and its own criteria of efficiency” (2008, p. 30). Not only did the wealth of the colonies bolster Western development but many technological, agricultural, and pharmacological advances originate in appropriated indigenous knowledge and practices which have sustained communities and worked in harmony with the environment for many generations.
So here I am in graduate school struggling with the confines of discipline, contradictions in the ownership and authorship of research based in community experiences, and grieving the fact that Western medicine (midwifery) can actually harm people. I believe we’re in this grand environmental and social catastrophe because of the inherently self-interested, short-term, national chauvinistic and narrow-minded nature of the capitalist system. I’m inspired by Richard Levin’s “Living the 11th Thesis” and his call, which in some ways is similar to CP Snow – to meld the social and natural sciences – but in many ways different – to meld academia with social justice. Our scientific endeavors can and must respect unique (and oft poorly understood) world views, uphold human rights and self-determination, promote reciprocal collaboration, and contribute to the betterment of humanity. My attempts to live the 11th Thesis are to enter my research with intention to make change, to shift the practice of midwifery care, and to incorporate the concept of social justice in all aspects of my work. Living the 11th thesis keeps alive the challenges that brought me to my research to begin with: the discounting of the voices of the ‘other’ in clinical work, the overemphasis on Western biomedical viewpoints, and the underlying truth that Registered Midwifery is predominantly a white, middle class, colonial project.
- Krieger, N. (2012). Methods for the Scientific Study of Discrimination and Health: An ecosocial approach. American Journal of Public Health, 102(5), pp. 936-945.
- Lélé, S. & Norgaard, R.B. (2005). Practicing Interdisciplinarity. BioScience, 55(11), pp. 967-975.
- Levins, R. (2008). Living the 11th Thesis. Monthly Review, 56(8). Available on line.
- Marx, K. (1845). Theses on Feuerbach. Available on line.
- Oakley, A. (1998). Gender, Methodology and People’s Way of Knowing: Some problems with feminism and the paradigm debate in social science. Sociology, 32(4), pp. 707-731.
- Snow, C.P. (1961). The Two Cultures and the Scientific Revolution [the Rede Lecture]. New York: Cambridge University Press.
Being a Renaissance Wo/man: Modern education, interdisciplinary research and a multidisciplinary life
An engineer-scientist-painter-sculptor-inventor? That is an impressive, if disparate combination and of course describes Leonardo Da Vinci. From religious art to human anatomy to bicycles, Da Vinci had rather multidisciplinary interests. He is the eponymous Renaissance man. Merriam-Webster defines a renaissance man, sadly with no equivalent definition for a renaissance woman but let’s assume they are one in the same, as someone who has “wide interests and is expert in several areas”. In Renaissance Europe, being an academic was not the sole propriety of the scientific discipline. Rather a rounded education resulted in great inventors also being master artists. Fast forward 500 years and this archetype is virtually unknown, what would such a rare creature even look like in today’s academic world?
…in modern education…
The modern Renaissance person would learn about a variety of subjects, equally applying their interests in various scientific and artistic pursuits. Transferring this concept to North American post-secondary education, students would study sciences like chemistry, mathematics, biology but also perhaps theatre, art history and English literature. Not to mention the numerous other disciplines ranging from beer brewing to environmental archaeology. Though I would argue that one would be infinitely more interesting while consuming the products of the other. Basically this person would acquire at least a base knowledge in several different disciplines. This can happen, especially in universities like my own with a focus on interdisciplinarity, but is not the rule for the majority of academics (Castán Broto, Gislason & Ehlers, 2009).
…in academic research…
In academic research, there is a special application of the Renaissance perspective, namely interdisciplinary research. Defined, varyingly in sources, as collaborative examination of a research problem from two or more disciplines (Choi & Pak, 2006). In this concept the researchers are not themselves Renaissance men but rather they take a Renaissance-like perspective on the problem at hand. The goal is to understand the research question in a more holistic way (Choi & Pak, 2006). The problem with applying Renaissance ideals to research is it clashes directly with university structure. We become increasingly specialized through Masters and Doctorate degrees, limiting our perspectives but becoming experts in one particular field (Castán Broto, Gislason & Ehlers, 2009). In this current structure, understanding where another discipline may add to our research is complicated. Science has greatly evolved since the 16th century; modern technology is difficult to keep up with within my own field, let alone understanding the context of another discipline. Therefore to examine an issue from multiple perspectives requires immense time and effort (Lélé & Norgaard, 2005). Interdisciplinary research teams are just beginning to chip away at the possibilities.
…in academic life…
What about beyond the doors of the university? What does a “true” Renaissance man or woman look like? A quick Google search for modern renaissance men and women produces many actors and a few academics. The criteria seems a bit confusing as I think many would agree Justin Timberlake wouldn’t be their first choice. According to this quiz I am “Totally Renaissance”, I must be doing something right. In this category being a Renaissance person is, well, personal. What we consider to be different and interesting is up to the individual. Someone who loves jazz and molecular biology is as much “Renaissance” as someone who studies anthropology and has an active interest in feminist literature. In the classical sense, your interests should include some kind of art as well as science (“Renaissance man”, n.d.). Where those lines are drawn is up to you, no pun intended.
…as an ideal.
In the end, what ideal are we working towards by being Renaissance? Da Vinci was no doubt a genius, but is being a Renaissance wo/man a goal in itself? What inherent value is there in having multidisciplinary interests? With research the benefit is clear, we can see a question in new and potentially more accurate ways. From a personal perspective, having an interest in theatre, sociology and chemistry may help you approach your research in innovative ways and perhaps improve your life.
A self-described epidemiologist-pianist-film fan-amateur archaeologist-photographer-travel enthusiast-home cook-general geek-voracious reader-graduate student.
- Choi, B.C.K. & Pak A.W.P. (2006). “Multidisciplinarity, interdisciplinarity, and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness.” Clinical and Investigative Medicine, 29, 351-364.
- Lélé, S. & Norgaard, R.B. (2005). Practicing interdisciplinarity. BioScience, 55(11), 967-975.
- Renaissance man. (n.d.) In Merriam-Webster online. Retrieved from http://www.merriam-webster.com/dictionary/renaissance%20man
- Castán Broto, V., Gislason, M. & Ehlers, M.-H. (2009). Practising interdisciplinarity in the interplay between disciplines: experiences of established researchers. Environmental Science and Policy, 12(7), 922-933.
- Leonardo da Vinci (1452 -1519). (n.d.) Retrieved February 2, 2014 from http://www.bbc.co.uk/history/historic_figures/da_vinci_leonardo.shtml