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The Cost of Courage

It takes courage. Because the injury often comes from colleagues or institutions who should have your back. A betrayal of trust. It hurts.


Professor Michael Joyner from the Mayo Clinic boasts a named professorship, a distinguished investigator award, and continuous research funding from the NIH since 1993. He defines what it means to be an expert in his field of exercise physiology. Then he dared enter the space of ideas regarding transgender athletics.


He was shut down from a direction that caught him unaware. It was his own institution. The Mayo Clinic. A place of medical innovation. A place of science. The last place one would have imaged marginalizing one of its own distinguished scientists.


Joyner was suspended and now works under an expansive gag order for not adhering to prescribed messaging.


Dr. Tom Jefferson, senior clinical tutor at University of Oxford, has studied physical interventions to limit spread of respiratory viruses since 2006. He is a British epidemiologist and is an author and editor of the Cochrane Collaboration’s acute respiratory infections group, as well as four other Cochrane group. He was the one who did the TamiFlu analysis. An evidenced based medicine legend.


Jefferson was the lead author of the latest update of the Cochrane Report which came out Jan 30, 2023, which, after reviewing all randomized trials of masking, came to two conclusions:


1. Compared with wearing no mask in the community studies, wearing a mask makes little to no difference in how many people caught a flu-like illness or Covid like illness.


2. Wearing a mask also made no difference in how many people have flu/Covid confirmed by a laboratory tests.


The criticism was immediate. Mask advocates claimed that the report did not prove masks don’t work, but just failed to find benefit. The absence of evidence is not evidence of absence. The problem with this argument was that this is a new standard – just for masks.


Much of the resistance came from his own institution. In an interview, Jefferson acknowledged: “In early 2020, when the pandemic was ramping up, we had just updated our Cochrane review ready to publish…but Cochrane held it up for 7 months before it was finally published in November 2020.”


He added, “During those 7 months, other researchers at Cochrane produced some unacceptable pieces of work, using unacceptable studies, that gave the “right answer. “


Zeynep Tufecki is a sociologist who wrote an op-ed in the NY times in first quarter 2020 and is credited with getting the CDC to push masks on the American public – without randomized evidence – including in children. She produced a NY Times op ed in response to the Cochrane study, “Here’s Why the Science is Clear that Masks Work.” Tufecki went on to cite a bunch of low credibility studies to support masks.


It was embarrassing. It was like citing mouse model research that a drug should work after the pooled analysis of randomized, phase 3 trials show it doesn’t.


Dr. Jefferson responded to her personal attacks on him, “I have never met Zeynep Tufeckci, but the one descriptive review she has written on SARS-CoV-2, is only cited in the Introduction to our Cochrane Review and not included in it, as it does not meet our inclusion criteria or definitions for a systematic review.”


What was more hurtful to Jefferson was when the Cochrane’s Editor in Chief published a statement that Jefferson misinterpreted his own study’s finding on masks. That editor then offered a statement of apology which was not supported by any of the authors of the review.


Since NIH is a major funder of Cochrane, the rhetoric is not surprising. But do you see the problem?


If Doctors Michael Joyner and Tom Jefferson can be sanctioned, what chance is there for you or me?


Emerson once urged academics to think publicly, clearly, and not influenced by tradition or history. Dr. Harlan Krumholz grew the once small “Circulation – Cardiovascular Quality and Outcomes” from a small insignificant publication into a prominent journal in Cardiology. He wrote an essay in 2012 as he retired from his position of editor in chief of “Circulation”. It’s about a 7-minute read.


It’s worth your time.


A Note to My Younger Colleagues. . .Be Brave


Originally published 1 May 2012 https://doi.org/10.1161/CIRCOUTCOMES.112.966473 Circulation: Cardiovascular Quality and Outcomes. 2012;5:245–246


In some ways, our best hope to reveal our follies lies with those new to the field. It is your fresh eyes, unbridled enthusiasm, optimism about what is possible, and commitment to the highest ideals of the profession that can reveal what those who have longer tenure in medicine may have trouble discerning. And yet, to be effective and make use of those insights, you must be brave. Surely, you must also be judicious and prudent in expressing yourself, making sure that your opinions are informed and grounded in science. But when there is an opportunity to speak truth to power, I hope you will consider doing it.


Unfortunately, our profession does not often reward those who question dogma. In fact, there are many episodes throughout the history of medicine and science in which truth was resisted and dogmatic beliefs, however poorly supported by evidence, were imposed by those in a position to do so. If we are to accelerate innovation in medicine, eliminate wasteful practices, and improve the depth and effectiveness of how we care for patients, then there must be room to question traditional approaches and to introduce new and better ways of prevention, diagnosis, and treatment. We are now at that critical juncture.


When I entered medicine, I did not realize that there was such intense pressure to conform. But we learn early on that there is a decorum to medicine, a politeness. A hidden curriculum teaches us not to disturb the status quo. We are trained to defer to authority, not to question it. We depend on powerful individuals and organizations and are taught that success does not often come to those who ask uncomfortable questions or suggest new ways of providing care.


The sense of danger that we feel when we question authority is not unfounded. Those who ask difficult questions or challenge conventional wisdom are often isolated. They may find few opportunities to speak, and their writings may not be welcome. Compliance with normative behavior may be forced by fear of recrimination. In some cases, junior faculty may fear that support from mentors will be withdrawn or promotions denied.


I have seen evidence of many such efforts to coerce conformity of opinion and behavior. I have heard of junior faculty who were told that questioning key assumptions of the field, even with evidence, would result in threats to funding and support. I am aware of individuals in nationally prominent organizations whose ability to attain leadership roles was stymied when they raised important questions about organizational strategy, while those who were more compliant progressed. I know individuals whose criticisms of popular products made them the targets of industry efforts to undermine their credibility. I have experienced the exercise of power in the spirit of quieting dissent and debate rather than supporting and encouraging it.


I have grown to appreciate those who will stand up despite the risks or in the face of efforts to silence them. Promoting the best science and the best advocacy for patients and the public sometimes entails risk. Change does not come easily to a system and there is resistance to those who may seek to make the system safer, more effective, and more patient-centered through new ideas or the articulation of uncomfortable truths.


A friend and role model, Victor Montori, who is a faculty member at Mayo Clinic, responded eloquently to a young research fellow who was advised, at an early stage in his training, to avoid a controversy in which he questioned the logic of a prominent study. Montori crystallized the issue in the following e-mail, which he has given me permission to share:


I have struggled with this issue for years. Turns out that this is a common struggle for those who find themselves unable to stay silent in the face of waste, error, low integrity, or abuse.


If you find yourself with some time (not a lot), let me recommend Letters to a Young Contrarian by Hitchens.1 His argument that clarity emerges from conflict is compelling. And for conflict to emerge, ie for clarity to emerge, someone has to take a position. The question you ask is whether this should be you, now, and at this stage of your career.


The threat that if you express your thoughts that this very expression will negatively dispose you to funding and advancement suggests to me that you are receiving advice from folks who choose their battles ‘wisely.' I think one needs to be mindful and respectful and go to battle when important and necessary. Yet, around here, though, people who ask that you choose your battles are indeed expressing fear of conflict. They are often more invested in themselves and their advancement than on the quest for clarity. While I understand their behavior, my personal choice is not to admire it or seek to emulate it.


If you learn by critical analysis and thinking, if you share the results of this thinking with passion and honesty, you will find fertile ground for growth. This may not happen with certain people or in certain places but will happen. You will also attract to your side people who feel strongly about honesty and integrity in science—people worth being around not only because they enjoy the work and do so with passion, honesty, and integrity, but because they will hold you and your work to the same measures of accountability. And guess what? That can only make your work and the world you are trying to change better.


Will your path toward growth be more difficult? Perhaps. Would you have it any other way?


If you take the path toward clarity, I guarantee that you will occasionally find people who will disparage you. They may seek to undermine you, find ways to marginalize you, and try to incriminate you. They may come from directions that surprise you. Powerful ideas often attract attacks that focus more on individuals than ideas. If you raise inconvenient truths or voice uncomfortable opinions, particularly if they threaten someone's comfortable status quo, then you will discover much about the character of those with whom you disagree. But always take the high road, engage in dialogue about ideas and evidence, and be motivated by the opportunity to best serve patients and the public. You will not regret it.


Circulation: Cardiovascular Quality and Outcomes welcomes science that questions conventional wisdom or charts a path toward better care. Our pages commonly have contributions that address, or even cause, controversy. For example, we published a series of opinion pieces about open science in the last issue as part of a call to consider facets of the argument surrounding changing the culture of research.25 In the same issue, Hauser and colleagues6 took aim at our current method of post marketing surveillance of devices and evaluated the utility of an automated safety surveillance system. In a prior issue, Sussman and colleagues7 criticized the national guidelines for aspirin and used strong methods to make a case for a better approach.


Many of our authors raise uncomfortable issues, and we welcome them provided that the science and logic of their arguments are strong, and their focus is on the topic rather than the individuals involved. We do not preclude anyone from contributing ideas; we only ask that our authors disclose their relationships that could be perceived as influential. In the end, the best science and arguments should hold sway regardless of who is making them. That person may be someone new to the field or someone with a perceived conflict or someone who is not ordinarily considered an “expert.”


Ultimately, our success as a profession will depend on our ability to engage in debate, acknowledge different opinions, and seek answers through science. The more we depart from the evidence, the more difficult it is to resolve differences. It is critical that we seek truth through science and be humble enough to acknowledge uncertainty. Dogma based on opinion must be reduced from a position of infallibility to one of supposition. For example, only now is the treat-to-cholesterol target dogma of our past prevention guidelines giving way to open discussion surrounding the lack of trial evidence to support the value of intensifying therapy, particularly with non-statin medications, to achieve targets.8 We must foster a generation of clinical scientists—outcomes researchers and clinicians—who naturally question, in respectful ways, the assumptions of the past.


Defining moments can occur when you least expect them. Are you prepared to respond in a way that will bring honor to you and our profession? If you are prepared to let science lead you to your conclusions, then your work and your ideas will find a venue in these pages. Patient-centered improvement will require such a commitment from all corners of our profession. Be brave.


And let it be noted that there is no more delicate matter to take in hand, nor more dangerous to conduct, nor more doubtful in its success, than to set up as a leader in the introduction of changes. For he who innovates will have for his enemies all those who are well off under the existing order of things, and only the lukewarm supporters in those who might be better off under the new. This lukewarm temper arises partly from the fear of adversaries who have the laws on their side and partly from the incredulity of mankind, who will never admit the merit of anything new, until they have seen it proved by the event.


—Machiavelli, 1532


Sources of Funding

Dr Krumholz is supported by grant U01 HL105270-02 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute.


Disclosures

Dr Krumholz is the recipient of a research grant from Medtronic, Inc, through Yale University, and is chair of a cardiac scientific advisory board for UnitedHealth.


Footnotes

The opinions expressed in this article are not necessarily those of the American Heart Association.


Correspondence to Harlan M. Krumholz, MD, SM,

1 Church St, Suite 200, New Haven, CT 06510


References

  • 1. Hitchens C. Letters to a Young Contrarian. New York: Basic Books; 2001.Google Scholar

  • 2. Gøtzsche PC. Strengthening and opening up health research by sharing our raw data. Circ Cardiovasc Qual Outcomes. 2012; 5: 236– 237 .LinkGoogle Scholar

  • 3. Krumholz HM. Open science and data sharing in clinical research: basing informed decisions on the totality of the evidence. Circ Cardiovasc Qual Outcomes. 2012; 5: 141– 142 .LinkGoogle Scholar

  • 4. Ross JS, Lehman R, Gross CP. The importance of clinical trial data sharing: toward more open science. Circ Cardiovasc Qual Outcomes. 2012; 5: 238– 240 .LinkGoogle Scholar

  • 5. Spertus JA. The double-edged sword of open access to research data. Circ Cardiovasc Qual Outcomes. 2012; 5: 143– 144 .LinkGoogle Scholar

  • 6. Hauser RG, Mugglin AS, Friedman PA, Kramer DB, Kallinen L, McGriff D, Hayes DL. Early detection of an underperforming implantable cardiovascular device using an automated safety surveillance tool. Circ Cardiovasc Qual Outcomes. 2012; 5: 189– 196 .LinkGoogle Scholar

  • 7. Sussman JB, Vijan S, Choi H, Hayward RA. Individual and population benefits of daily aspirin therapy: a proposal for personalizing national guidelines. Circ Cardiovasc Qual Outcomes. 2011; 4: 268– 275 .LinkGoogle Scholar

  • 8. Hayward RA, Krumholz HM. Three reasons to abandon low-density lipoprotein targets: an open letter to the Adult Treatment Panel IV of the National Institutes of Health. Circ Cardiovasc Qual Outcomes. 2012; 5: 2– 5 .LinkGoogle Scholar

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