A Confederacy of Dunces

The past two years, and the two that will follow, are all about giving you knowledge…. But
the day will soon come when the dissemination of knowledge will cease. And on that day, will be first day of the rest of your life. The quality of your craft… and the magnitude of what you can do for your patients… will hinge entirely upon how empowered you are to teach yourself. The medical literature exists for this reason… not only to advance the profession’s collective knowledge, but also to enable physicians to extend their knowledge such that the world does not pass them by.

Your ability to teach yourself after medical school is entirely dependent upon your ability to navigate the road of the medical literature… Those who master it will eventually be great. Those who do not, will be antiquated even before the game starts.

These are the words passed on to my class by our Chief of Medicine. Medical knowledge changes and evolves very quickly, and it is imperative for physicians and physicians-in-training to constantly cultivate our minds, our most valuable tool in the art of healing. The medical training process places a strong emphasis on the prerequisite of demonstrated intelligence and the sharpening of our analytical skills. I see this as a two-pronged approach: the honing of our minds to make it a more effective tool of analysis, and the maintenance of knowledge hygiene to help us differentiate between truth and falsehood.

However, it is a difficult task, and one that many people are not eager to do. It’s too easy for students to focus on what is “enough” or “sufficient”: the amount of knowledge we need to know seems to keep growing beyond the capacity of our slowly expanding minds. On the one hand, I wonder if it is too early for my class to be exposed to medical literature in detail (such that they might not understand its importance); on the other hand, I think that this is a late introduction, perhaps too late for some to develop a level of comfort that makes the reading and critical thought feel natural. Today, while leading the discussion of a paper in the first of three journal club sessions of a small group of classmates, it became very obvious to me that several of my classmates are quite proficient in mentally handling medical research (i.e. being able to discuss a study on an unfamiliar topic) and several more of my classmates are possibly reading papers for the first time. I remember how painful and tedious those first experiences were. Nonetheless, it’s necessary to resist the urge toward mere “adequacy”: it is this tendency that has entrapped our predecessors in the habit of allowing themselves to be swayed by the marketing of pharmaceutical representatives, too often not to the benefit of patients.

On this backdrop, it’s hard for me not to find reason to be disgusted in a seemingly distant event: the attempts of the pharmaceutical company Pfizer to force the breaking of confidentiality of reviewer reports for clinical trials on Pfizer’s drugs published in the New England Journal of Medicine. Many might wonder what might be the relevance of this legal action. There is nothing “sacred” about the peer review process: it’s quite simply an essential condition for the proper evaluation of scientific research. In order to properly evaluate studies, editors of journals ask a few intelligent leaders within a field to read and critically evaluate studies before they are accepted for publication. In this process, experts in a field are able to weigh in on the findings, see if the findings make sense and match the assertions of the authors, and suggest the new for additional experiments or additional evidence to support the claims. This is a confidential process, and the importance of the confidentiality lies with the reviewer: some wish to have confidentiality, others might not and would be happy to speak directly to the study’s authors. However, when dealing with giants, one must be careful: good scientists who have spoken out against giant pharmaceutical companies are often targets and can end their careers in the fight for truth. The confidentiality of peer review protects physician-scientists and non-physician researchers from the heavy-handed tactics of industry and other groups who have strong financial interests in the publication of positive or negative studies related to medical treatments.

Without this measure, we live in a tyrannical environment predicated on fear and marked by the further silencing of those who would seek to uphold the truth and protect us. We, physicians and future physicians, rely on the distribution of new, truthful knowledge by medical journals, because we have no guarantee of truth offered through the brochures, presentations, dinner talks, and advertisements given to us by pharmaceutical and biotechnology companies. We rely on our peers, our fellow physicians, and not those who wish to use us.

This is by no means an attempt to cast a halo upon journal editors: they may have bias, they may have fault in their reasoning, and they may have agendas not in accordance with the well-being of the public. However, it is the universal task of journal editors to critically evaluate research and determine its truth and relevance. The more they strive for truth and succeed in this task, the more they are respected and the more their selection and opinions are valued. To this end, it’s not for naught that NEJM is the most respected, valued, and competitive of medical research journals, and similarly, it’s not surprising that it is frequently the target of attacks by the pharmaceutical industry and other interest groups who would like to see this measure of protection eliminated for their financial gain. Which brings me back to my class and our begrudging task of learning how to navigate the medical literature: Please learn this skill, for we are surrounded by a confederacy of dunces that seeks to take advantage of us to the detriment of ourselves and our patients.

“When a true genius appears in the world, you may know him by this sign, that the dunces are all in confederacy against him.” – Jonathan Swift


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