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Medical Ethics |

Limitations of Medical Research and Evidence at the Patient-Clinician Encounter ScaleLimitations of Medical Research and Evidence

Alan H. Morris, MD, FCCP; John P. A. Ioannidis, MD, DSc
Author and Funding Information

From the Pulmonary and Critical Care Divisions, Departments of Medicine (Dr Morris), Intermountain Medical Center, Intermountain Healthcare and The University of Utah School of Medicine, Salt Lake City, UT; and Stanford Prevention Research Center (Dr Ioannidis), Department of Medicine, and Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA.

Correspondence to: Alan H. Morris, MD, FCCP, Pulmonary/Critical Care Division, Sorenson Heart & Lung Center, 6th Floor, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157-7000; e-mail: alan.morris@imail.org


Funding/Support: This work was supported by the National Institutes of Health [RO1-HL-36787, NO1-HR-46062], the Agency for Healthcare Research and Quality (HS 06594), the Intermountain Research & Medical Foundation, the National Respiratory Distress Syndrome Foundation, the LDS Hospital, and Intermountain Healthcare, Inc (all to Dr Morris). The work of Dr Ioannidis was supported by an unrestricted gift by Sue and Robert O’Donnell.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(4):1127-1135. doi:10.1378/chest.12-1908
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We explore some philosophical and scientific underpinnings of clinical research and evidence at the patient-clinician encounter scale. Insufficient evidence and a common failure to use replicable and sound research methods limit us. Both patients and health care may be, in part, complex nonlinear chaotic systems, and predicting their outcomes is a challenge. When trustworthy (credible) evidence is lacking, making correct clinical choices is often a low-probability exercise. Thus, human (clinician) error and consequent injury to patients appear inevitable. Individual clinician decision-makers operate under the philosophical influence of Adam Smith’s “invisible hand” with resulting optimism that they will eventually make the right choices and cause health benefits. The presumption of an effective “invisible hand” operating in health-care delivery has supported a model in which individual clinicians struggle to practice medicine, as they see fit based on their own intuitions and preferences (and biases) despite the obvious complexity, errors, noise, and lack of evidence pervading the system. Not surprisingly, the “invisible hand” does not appear to produce the desired community health benefits. Obtaining a benefit at the patient-clinician encounter scale requires human (clinician) behavior modification. We believe that serious rethinking and restructuring of the clinical research and care delivery systems is necessary to assure the profession and the public that we continue to do more good than harm. We need to evaluate whether, and how, detailed decision-support tools may enable reproducible clinician behavior and beneficial use of evidence.


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