I had meant to move on from  this issue about the complexity of biomechanics and the quality of the research questions we ask … but then last night, in her comment, Quin drew my attention to a series of articles entitled “Biomedical research – increasing value, reducing waste” that were published in the Lancet in June (these are free to download but you need to register first – also free). They make fascinating reading. If you think I was a bit grumpy and cynical in what I wrote the week before last then you should have a look at what these guys are saying! (The articles are a bit heavy going and an easier and more entertaining alternative is Ben Goldacre‘s book Bad Science, it’s been around long enough that you can pick it up for 1p on Amazon and just pay the postage).

The issue marks the twentieth anniversary of an article, The scandal of poor medical research, written by the statistician Doug Altman in the BMJ which was perhaps the first public recognition of the poor quality of much clinical research with the tag line, “we need less research, better research and research done for the right reasons“. In another commemorative piece, Medical research still a scandal,  Richard Smith, who was editor of the BMJ at the time, laments on how little has changed, despite, perhaps, a wider awareness of the problems.

One of the responses to Bland’s original article which appealed to me has been given the title Theory must drive experiment. In it the author (a JA Morris from the Royal Lancaster Infirmary) attributes the problem of poorly formulated research questions to a failure of clinical scientists to develop an underlying theoretical basis for their experimental observations. This has always puzzled me as well and, over the years, I’ve come to the conclusion that, as someone who trained originally as a physicist, I’ve got a markedly different view of the world to many of my colleagues who trained in medicine or health sciences.

Arthur Eddington, “… do not put too much confidence in experimental results until they have been confirmed by theory”

As a physicist I expect to understand the results of my experiments and to be able to align them with an underlying theory. An understanding of that underlying theory then develops new research questions. My  knowledge continues to develop by the continued construction and refinement of the underlying theory (I’m sure there is a posh name for this in the philosophy of science). Taken to an extreme this results in Eddington‘s warning to the physicist  not to “put too much confidence in experimental results until they have been confirmed by theory“. Whilst at face value this sounds like an injunction against publishing experimental data it is actually a plea for careful consideration of the results in the light of the underlying theoretical framework and a refinement of that framework if  necessary.

Ernest Rutherford, “When it comes to science there is physics and there is stamp collecting”

I wouldn’t claim this as a unique skill of the physicist. Whilst over a hundred years ago Rutherford could quite reasonably(?) claim that “all science is either physics or stamp collecting” , the world has moved on. The rise of anatomy, physiology and particularly biochemical biology since that time mean that there are now underlying theoretical frameworks that we can use to explain the results of clinical and health sciences research.

We very rarely do though and I think this is partly attributable to education of doctors and allied health professionals being rooted in an earlier era. It wasn’t so very long ago that most results of clinical research where, effectively, beyond explanation. There was no point trying to fit those results into any underlying theoretical framework because the basic principles of that framework had not been established.  Knowledge in the clinical domain was essentially phenomenological – a knowledge of what happens rather than why it happens. Education then becomes a matter of teaching the facts rather than the underlying principles that link those facts. Of course if you don’t have an underlying theory to work from then you are going to find it much more difficult to generate sensible questions to drive the next generation of research. This is, of course, exactly the point that Morris was making and links to my post from last week.

As we move out of that era though we’ve got to put a much heavier emphasis on developing the underlying theoretical basis of our subject and using this to drive our research questions. Which leads me to my highlight of the ESMAC-SIAMOC conference which was Adam Shortland’s key-note talk, “The neuromuscular prerequistes of normal walking and the early loss of ambulation in cerebral palsy“. In it he reviewed what is now known about neurophysiological development and laid out a conceptual framework that explains much of what we observe in cerebral palsy and also provides a platform to generate new research questions … but then if you look at his CV you’ll see that he trained first as a physicist as well!