I can definitely see value in adding a "best use by date" for clinical evidence. But personally my biggest problem is the quality of most research and the heavy bias in them these days. So we'd need a lot of caveats, not just dates. And population risk baseline shifts are in constant flux. ASA in primary prevention, statins for CVD, beta blockers for hypertension all have shifted because of better options being available, patients having different leading risk factors, new screening tools, and more effective (or more unaffordable) treatments. To truly capture someone's risk in such a rapidly evolving patient cohort I'm sure we'll need a more robust approach. But starting with an expiration date is definitely a good start.
The bigger problem is advising patients who have been trained on social media data. Most doctors don't have an audience with adequate attention span or health literacy, much less the time in their clinics to explain such deep concepts.
I have required reading material for my patients. It's a high-touch virtual medical practice and I can only help my patients if our knowledge gap is narrow. I don't know another way. The past 2 decades when I just prescribed meds based on what UpToDate recommended certainly weren't fruitful years for me or my patients.
Interesting piece. Incidentally, you will probably wish to change "aspiring" to "aspirin" in the text. Visual displays never carry the weight of a "number" that says: "Greater than this -- expired; less than this -- still relevant" or some other such scale. that would seem to be the next step in making this a practical tool that is widely used. But all research needs much more of this thinking.
Should there be expiration (“dates”) for evidence? I would unequivocally say yes.
But as the authors note, time may not be the only relevant criterion.
So the next question is how to determine if something has in fact expired? The answer to me would be updated evidence (ie new trials). But of course that is no small undertaking, and involving therapies that will have long lost patent protection and hence industry interest.
The BB post MI story has been the poster child for this in the last 2-3 years. But that’s a 40 year stretch (from adoption to reversal).
So it’s unclear to me how one determines if and when something deserves a re-look.
As a biased observer (retired radiologist), I have been saying the physical exam to be outdated in many contexts. When the famous diagnosticians of the late 19th and early to mid 20th centuries wrote their textbooks, people didn't come to hospitals or doctors until really sick, so classic signs and symptoms were often present. But, in the office now, the pre-test probabilities are so much lower that hoofbeats are very faint. Thus, one has to decide between doing nothing, versus really specific tests, as wishy-washy ones like the PE don't change that pre-test probability enough to be useful. OTOH, I am sure there is value in laying on of the hands and getting to know a patient with whom one hopes to have a long term relationship, less directly related to Bayesian calculations.
Very good article. The context changes with time, so agents that worked years ago may not work today.
I can definitely see value in adding a "best use by date" for clinical evidence. But personally my biggest problem is the quality of most research and the heavy bias in them these days. So we'd need a lot of caveats, not just dates. And population risk baseline shifts are in constant flux. ASA in primary prevention, statins for CVD, beta blockers for hypertension all have shifted because of better options being available, patients having different leading risk factors, new screening tools, and more effective (or more unaffordable) treatments. To truly capture someone's risk in such a rapidly evolving patient cohort I'm sure we'll need a more robust approach. But starting with an expiration date is definitely a good start.
The bigger problem is advising patients who have been trained on social media data. Most doctors don't have an audience with adequate attention span or health literacy, much less the time in their clinics to explain such deep concepts.
I have required reading material for my patients. It's a high-touch virtual medical practice and I can only help my patients if our knowledge gap is narrow. I don't know another way. The past 2 decades when I just prescribed meds based on what UpToDate recommended certainly weren't fruitful years for me or my patients.
Interesting piece. Incidentally, you will probably wish to change "aspiring" to "aspirin" in the text. Visual displays never carry the weight of a "number" that says: "Greater than this -- expired; less than this -- still relevant" or some other such scale. that would seem to be the next step in making this a practical tool that is widely used. But all research needs much more of this thinking.
Should there be expiration (“dates”) for evidence? I would unequivocally say yes.
But as the authors note, time may not be the only relevant criterion.
So the next question is how to determine if something has in fact expired? The answer to me would be updated evidence (ie new trials). But of course that is no small undertaking, and involving therapies that will have long lost patent protection and hence industry interest.
The BB post MI story has been the poster child for this in the last 2-3 years. But that’s a 40 year stretch (from adoption to reversal).
So it’s unclear to me how one determines if and when something deserves a re-look.
I would just settle for evidence. Just provide the raw data of every study. Such a low bar but here we are.
As a biased observer (retired radiologist), I have been saying the physical exam to be outdated in many contexts. When the famous diagnosticians of the late 19th and early to mid 20th centuries wrote their textbooks, people didn't come to hospitals or doctors until really sick, so classic signs and symptoms were often present. But, in the office now, the pre-test probabilities are so much lower that hoofbeats are very faint. Thus, one has to decide between doing nothing, versus really specific tests, as wishy-washy ones like the PE don't change that pre-test probability enough to be useful. OTOH, I am sure there is value in laying on of the hands and getting to know a patient with whom one hopes to have a long term relationship, less directly related to Bayesian calculations.
Cochrane’s sainthood in medical education should be tempered - this reason being a big one.