The Great Stagnation and Evidence-Based Medicine

For me, the Great Stagnation (Tyler’s term) or the Innovation Shortfall (my term) is concentrated in the biosciences. Here we’ve thrown  enormous scientific, corporate and public resources into biosciences, and made tremendous scientific advances.  Yet the prize of cutting-edge treatments seems further and further away.  Take this new study, which started with a simple hypothesis about sepsis, and ended up with a much more complicated picture:

Researchers from Rhode Island Hospital have identified a protein that plays a dual role in the liver during sepsis. The protein, known as RIP1, acts both as a “death switch” and as a pro-survival mechanism. …Ayala says, “We initially hypothesized that RIP1 was involved in the alteration of the apoptotic death pathway to result in a kind of ‘programmed necrosis’ in the liver. What we actually found was an alternative role for RIP1 in the pathobiology of sepsis in the liver — one that also promotes cellular survival.”…..McNeal says, “The function of RIP1 is much more nuanced than we originally thought.”

These are questions that could not be even asked before. And at every step, the answer turns out to be more complicated than  we thought.

But then it occurred to me. If new research is continually suggesting that  things are really much more complicated than  we thought, how much of the medicine we are actually practicing now is correct? A new report suggests that we should be worried:

Even when following medical guidelines to the letter, doctors often use treatments that have little or no scientific support, U.S. researchers said Monday.

They found only one in seven treatment recommendations from the Infectious Diseases Society of America (IDSA) — a society representing healthcare providers and researchers across the country — were based on high-quality data from clinical trials.

By contrast, more than half the recommendations relied solely on expert opinion or anecdotal evidence.

“Despite tremendous research efforts, there is still a lot of uncertainty as to what is the best patient care,” said Dr. Ole Vielemeyer, an expert in infectious diseases at Drexel University College of Medicine in Philadelphia and one of the study’s authors.

Oh, okay. Let me bring the Great Stagnation, the biosciences revolution, and evidence-based medicine into a single framework.

The conventional wisdom was that breakthroughs in understanding the human genome  would provide better treatments within the existing structure of medicine–like  putting better windows or a new floor or more comfortable furniture into an existing house.  The implicit belief is that we could build on existing medical knowledge, add in the new knowledge of the genome, and quickly get to new products.

But what if the main lesson of the  past ten years is that the house itself has rotten foundations and needs to be rebuilt completely?  What if  the biosciences sector can’t afford to take anything for granted from existing medicine because too much of it is not evidence-based?

This is both bad news and good news.  Starting from scratch and rebuilding foundations is obviously a daunting and expensive task. and helps explain why the biosciences sector has struggled to produce breakthrough treatments.  On the other hand, when you are rebuilding foundations, a lot of progress can be made without anything visible from the outside.

I just know I’m going to get a lot of pushback on this hypothesis.  Take your best shot…I’m just thinking it through now, and I’m quite open to new thoughts.

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