QJM Advance Access published online on May 21, 2009
QJM, doi:10.1093/qjmed/hcp055
When I Use a word ... Changing your practice
Be not the first by whom the New are try’d,
Nor yet the last to lay the Old aside.
Alexander Pope, An Essay on Criticism
How many Oxford dons does it take to change a light bulb? Change?!?
The word ‘change’ comes from the Latin word cambire, to barter, but change is not always a good bargain. Many sayings deplore it. ‘Plus ça change plus ç’est la même chose’, said Alphonse Karr, talking about revolutions. And Ogden Nash thought that progress may have been all right once but that it had gone on too long.
On the other hand, bad practices abound and need to be changed, and even good practices become outdated as new technologies are invented and new ideas take root. For many years, the BMJ has run a column titled ‘A paper that changed my practice’, and NICE has published a document ‘How to change practice’,1 identifying barriers such as lack of awareness, knowledge, motivation, belief, and skill, and practical, financial, and political obstacles.
I recognize three broad types of publication that might change your practice. First, one that reminds or teaches you about something you already know or should—in other words, education;2 the BMJ's ‘Change Page’ aims to do this,3 and this type of publication may be a more powerful engine of change than original research. Secondly, a single research paper can occasionally change your practice, although to do so it would generally have to be an impressive piece of work—I discuss some examples below. Thirdly, a policy paper can establish general principles, changing your practice—NICE guidance documents fall into this category.
Can a single paper change your practice?
There are undoubtedly individual papers that have changed clinical practice or health-care outcomes. A paper on the use and adverse effects of minocycline in acne,4 with an accompanying editorial,5 probably immediately reduced prescribing of minocycline—the evidence is circumstantial but the time-course is convincing;6 this message has been repeated.7 A Lancet paper on the effects of measles virus on the gut8 rapidly changed public perception about MMR immunization, and affected public health. These two examples highlight one beneficial change and one adverse change. Neither was predictable.
In contrast, apoptosis9 took many years to achieve proper recognition (Figure 1). Barry Marshall's Nobel prize-winning observations of the role of Helicobacter pylori in peptic ulceration10 undoubtedly changed practice, but only after several years and in the face of considerable resistance;11 the association was not generally accepted until the early 1990s. In both of these revolutionary cases, practice was changed by the overwhelming force of evidence, not a single paper. I believe that there are many more examples of this than of the single practice-changing paper.
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Some reports of adverse drug reactions have rapidly occasioned withdrawal of the drug. The first anecdotal report of the oculomucocutaneous syndrome with practolol12 did that. However, there are very few examples of this compared with all reports.13 There are very few ‘between-the-eyes’ adverse effects that warrant immediate action.14 For each drug that has been rapidly affected by a report of its adverse effects there are hundreds that have not. In most cases, when the use of a drug changes, it is because of an accumulation of evidence rather than a single paper. Consider the prevention of osteonecrosis of the jaw associated with bisphosphonates—the first cases were detected in 2002, reports (now over 1000 cases) started to appear in September 200315 (barring a possible early case reported in 199516), proposals for preventive dental care emerged in 200517 and those proposals were then implemented.
Is it desirable for a single paper to change your practice?
Occasionally, an individual paper dictates withdrawal of a treatment. Intravenous diazoxide lowers raised blood pressure instantaneously, but this was shown to be dangerous18 and was abandoned, as was the habit of lowering blood pressure rapidly in accelerated hypertension. However, changes in practice are not always beneficial, as the example of MMR shows. Indeed, if, as Ioannidis has suggested, most research findings are false for most research designs and in most fields of research,19 papers that change your practice are likely to do so for the worse, or at least not for the better. Many ineffective or harmful therapies have entered practice in the absence of evidence about the balance of benefit and harm.20
Furthermore, medical practice usually progresses gradually, by accretion of knowledge a little at a time. Adopting a new treatment immediately on the basis of a single publication (which I call whizz-kid medicine) is unlikely to be wise. Someone has to be first, but do not let it be you, unless you thoroughly understand the pathophysiology of the disease, the mechanism of action of the intervention, and how the two can be married to produce appropriate therapy.21
Can editors and referees recognize papers that have the potential to change your practice?
The dictum that ‘prediction is very hard, especially about the future’ has been attributed to sages as diverse as Mark Twain, Albert Einstein, Niels Bohr and Yogi Berra. James Lind's observations on the use of citrus fruits in preventing scurvy took many years to be implemented by the Royal Navy.22 The first paper that suggested that rofecoxib (Vioxx) might cause an increased risk of cardiovascular disease had no effect until confirmatory data were published a few years later. Doubts23 about the risk of myocardial infarction with rosiglitazone, in the wake of a paper in the New England Journal of Medicine,24 highlight the difficulties in interpreting any new set of data, even a large meta-analysis. This is nothing new: consider tolbutamide, highlighted in two contrasting reports, 34 years apart.25,26
I doubt if editors and referees can spot papers that are really going to change your practice, or have the potential to, or even ‘research that has direct application in clinical practice, public health, or policy making’.27 How can they know that a paper will change your practice at all, or whether any such changes will be for the better or worse?
Conclusions
With others who have expressed concern about its decline,28 I greatly favour promoting more clinical research, which has suffered in recent years under various coshes, including overemphasis on -omics and the misguided research assessment exercises.29 However, editors should not ask ‘Will this paper change what our readers do or think?’ but ‘Will our readers be interested in reading this paper?’ Editorials, fillers, news items and reviews are more popular with medical readers than original research articles,30 and of all research papers, those that are the most read are those on adverse effects of drugs.31 Encouraging them to read original articles should be the aim. Perhaps editors should eschew peer review, draw attention to what they think is interesting, encourage debate and let the intellectual market decide.32
And perhaps, we should reflect on something that the stand-up poet, Luke Wright, has said: ‘Not everything has to change the world—sometimes it's just good to laugh.’33
Conflict of interest: none declared.
A previous version of this paper appeared in the BMJ rapid responses column (http://www.bmj.com/cgi/eletters/335/7610/0).
References
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33. Wright L. The way I see it. New Statesman (2007).
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