Abstract
To characterize patient satisfaction surveys, such as the U.S. government-mandated Press Ganey health care performance improvement tools, as unpopular among health care providers is an understatement. So it comes as no real surprise that among medical practitioners a recent internet headline went viral that “reported” that a major patient satisfaction study was stopped due to a mortality increase of 238% in patients who received patient satisfaction scores. 1 Despite some pretty obvious pointers to the nature of this news flash—starting with the outrageous numbers presented, to the contributing author being a “Doktor Schnabel” who quoted a “Prezz Gainey” health care organization, which referred to a study sporting an acronym called PISS (Patient Improvement Satisfaction Study)—this posting went viral and prompted comments that vented on the many limitations of patient satisfaction scores. Despite its farcical nature, the Gomerblog parody quite obviously managed to strike a raw nerve with dissatisfied health care providers, who were more than ready to pounce on anything discrediting this new government-mandated form of surveying prior to scrutinizing the source material closer.
This “news” coincided with a publicized report in the Journal of Science in which a major study was recalled based on suspicion of scientific flaws. 2 The New York Times, in addition to reporting on the background of this specific retraction, also presented an article examining a growing trend in flawed medical research. 3 There are many possible causes for this purported trend, but some of the causes were indentified, including undue observer bias and investigators wanting to prove a point using research tools while sacrificing sound scientific methodology. The editorials in the New York Times and other publications are spot on when they call into question the infallibility of medical scientific research. 4 The common thread of these two news items is that we as humans tend to put belief over fact, and when we need facts to support our beliefs, it is tempting to bend the prior to support the latter.
Regarding the sanctity of research, it is safe to say that there is no perfect research project or study. The underlying question at hand regarding the quality of research is that of motive and quality of execution on the part of the authors. For starters, are there reasons to believe that researchers are prompted by interests other than discovery? Have they, regardless of funding, done their best to reduce bias? Were the analytical methods employed really the most appropriate? Although the reviewers and publishers of most scientific journals do their utmost to detect and identify scientific shortcomings, even the most rigorous review procedures are not perfect.
Ultimately, publicized research has to stand up to a triple-stage review process: first comes the peer-aided journal review process; second, the publicized reader responses (letters to the editor, media reviews, errata, among others); finally, tertiary validation (finding corroboration over time through other studies or adoption into successful clinical practice). In the world of clinical science, the passage of time usually provides the penultimate judgment. Therefore, as investigators and reviewers alike we should be fueled by the pride in improving our patients’ well-being by sticking to sound scientific principles in our research endeavors and providing something that does not just slip by the initial review process but stands up to the more stringent but less formal secondary and tertiary review stages.
In this special Evidence-Based Spine-Care Journal (EBSJ) edition of the Global Spine Journal (GSJ), we present several studies that from a general perspective are poignant in this discussion about the validity of medical scientific research. In example, a Systematic Review article by Hanscom et al on the topic of cognitive behavioral therapy (CBT), which has been touted by some as a credible alternative to elective lumbar surgery, opened up the proverbial Pandora's box by evoking significant criticism from some of our reviewers regarding the paucity of “hard science” and the methodology used to try to stratify the available vast and diverse body of literature. In the end, GSJ/EBSJ resolved the issue by inviting the authors to resubmit their work as a Narrative Review. The intended benefit of exposing our surgeon readership to the current state of CBT outweighed the justifiable concerns of some of the reviewers. A Systematic Review by Hart et al looks at an increasingly common public perception that medical scientific publications tend to favor positive results and underreport negative or adverse events using the example of disk arthroplasty. An Invited Commentary explores the concept of using a formalized scoring process titled “clinical prediction rule” as an example of a standardized predictive analytical tool applied to cervical spondylotic myelopathy.
GSJ/EBSJ finds it important that its readership be aware of such emerging applications of formalized data gathering in our everyday clinical practices. The difficulties of creating “pure” clinical research can be seen in a prospective randomized study published in this issue of GSJ/EBSJ by Licina et al where a very busy center applied stringent inclusion and exclusion criteria, but in the end could not recruit the number of patients desirable for more differentiated statistical analysis. These and the other fine contributions in this edition are presented to our readership not from a position of wanting to “prove a point” but with the intent of inciting interest and discussions. As always, GSJ/EBSJ invites the collective wisdom of our global multispecialty spine surgeon community expressed in whatever form—criticism, clinical experiences, or corrections. Thank you for being part of the ongoing review process by contributing!