Paucity of peer reviewed literature discussions on this thread-why?

[drrinoo]

Recently, there were three threads on this forum 'mri before esi', 'isis anticoagulant guidelines', and 'intraspinal synovial cyst'

I have published on all three topics--this isn't a 'boo hoo' thread about why no one mentioned my name. This information is out there and in the vein of Cormac McCarthy--it doesn't matter if it is ever read; I'm happy with this body of work. However, none of the responses made an attempt to discuss the large body of knowledge on these subjects.

Peer reviewed publications pivot from other peer reviewed literature; all researchers make extraordinary efforts to cite the work of other authors,create their own imprint, and submit this work to an independent group of experts-- manuscripts are often rejected with humiliating comments--when it is finally published and presented for public consumption--colleagues in our own field still don't read these papers

So, is there any interest left in the peer reviewed literature? I roughly estimate that less than 1% of pain physicians publish--and if no one reads this stuff, is publishing still worthwhile to pain physicians? Would it be more practical to convince a medical director of an insurance company or an independent medical examiner or a jury during a malpractice trial with blog/forum posts instead of using peer reviewed literature?

(I may unleash the trolls, but I'm prepared)

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[101N]

Recently, there were three threads on this forum 'mri before esi', 'isis anticoagulant guidelines', and 'intraspinal synovial cyst'

I have published on all three topics--this isn't a 'boo hoo' thread about why no one mentioned my name. This information is out there and in the vein of Cormac McCarthy--it doesn't matter if it is ever read; I'm happy with this body of work. However, none of the responses made an attempt to discuss the large body of knowledge on these subjects.

Peer reviewed publications pivot from other peer reviewed literature; all researchers make extraordinary efforts to cite the work of other authors,create their own imprint, and submit this work to an independent group of experts-- manuscripts are often rejected with humiliating comments--when it is finally published and presented for public consumption--colleagues in our own field still don't read these papers

So, is there any interest left in the peer reviewed literature? I roughly estimate that less than 1% of pain physicians publish--and if no one reads this stuff, is publishing still worthwhile to pain physicians? Would it be more practical to convince a medical director of an insurance company or an independent medical examiner or a jury during a malpractice trial with blog/forum posts instead of using peer reviewed literature?

(I may unleash the trolls, but I'm prepared)

There are discussions of literature here all the time. I, for one, go out of my way to post stuff that I think will be controversial just to get people thinking/talking. And people respond. Like it or not, this is the best pain discussion board available, and it's free.

Reading between the lines, I think you what you are insinuating is that you don't see us posting articles from a certain journal here. I'm sure you know that that is because many of us consider it - and it's editorial board - to be unreliably biased toward positive results and shoddy peer-review. It's little more than the bully pulpit of Paducah.

 

[Ducttape]

I've been taught that reading the primary literature and studies and analyzing the studues myself is preferable to peer reviewed literature, which unintentionally or not will reflect the bias of the reviewers.

Also, pain management may not be as scholarly as other medical specialties, and bias is almost inherent to the field - just consider our outcome measures. With a large cadre of "pain physicians" already compromised by Big Pharma, I am doubly unlikely to "trust" anyone but EBM...

 

[Aether2000]

Peer reviewed does not in any sense mean unbiased or fair. It also does not necessarily reflect the general views held by most pain physicians, a standard of care, nor a work that would stand up in court. For instance, an expert witness recently selected 210mg of depomedrol as a yearly maximum dose and touted this as a standard of care because it was published in a peer reviewed journal. Turns out the 210mg/year was a misreading of the original literature based on 4 cases, and published in a journal by an author desperate to pad a fledgling journal with enough articles to keep the journal going. The journal was not listed in PubMed, National Library of Medicine, or many other standard measures of effectiveness at the time and did not require an IRB to oversee patient studies. Later the author attempted to clarify this misinterpretation in the same journal, but the damage was done. At least one expert witness and all the physicians in his practice have adopted as though gospel 210mg depomedrol as a yearly maximum for spine injections. Nevermind that they didn't bother to find out if this "peer reviewed" number had any validity- they instead are using it to skewer physicians in court using this "peer reviewed" information.

Point is: take everything "peer reviewed" or anything that touts itself as a guideline or standard of care with a grain of salt. For instance, the ISIS practice guidelines are simply a cookbook of practices based in part on the biases of the authors and only loosely on literature that support specific practices. There have not been in most cases comparative studies or placebo controlled studies showing the cookbook methods are any better than any other methods. There was no systemic literature review employed in their creation. Yet the ISIS guidelines are widely touted as standards of care, especially by some of their instructors. They are not. Instead, they represent logical consensus practice patterns that are espoused by one organization to enhance uniformity of conduct of a procedure and possibly enhance safety, yet safety is only enhanced if one recognizes and adjusts for variations in anatomy encountered.

So it is indeed appropriate to view standards, guidelines, best practices, cookbooks in light of who is doing the publishing, whether there is any internal conflict by publishing such guidelines or study (eg. the same organization publishing guidelines offers expensive courses that self servingly teach the procedures in such guidelines), whether the guidelines have broad application or are too specific, and how the guidelines were derived. For specific studies, does the author have any inherent bias to obtain such outcomes (selling a product or runs courses that teach about their specific approach), and is it published in a completely independent journal not controlled or influenced by the author. Only then can we have an intellectual discussion regarding specific merits of such "peer reviewed" literature.

 

[lobelsteve]

Peer reviewed does not in any sense mean unbiased or fair. It also does not necessarily reflect the general views held by most pain physicians, a standard of care, nor a work that would stand up in court. For instance, an expert witness recently selected 210mg of depomedrol as a yearly maximum dose and touted this as a standard of care because it was published in a peer reviewed journal. Turns out the 210mg/year was a misreading of the original literature based on 4 cases, and published in a journal by an author desperate to pad a fledgling journal with enough articles to keep the journal going. The journal was not listed in PubMed, National Library of Medicine, or many other standard measures of effectiveness at the time and did not require an IRB to oversee patient studies. Later the author attempted to clarify this misinterpretation in the same journal, but the damage was done. At least one expert witness and all the physicians in his practice have adopted as though gospel 210mg depomedrol as a yearly maximum for spine injections. Nevermind that they didn't bother to find out if this "peer reviewed" number had any validity- they instead are using it to skewer physicians in court using this "peer reviewed" information.

Point is: take everything "peer reviewed" or anything that touts itself as a guideline or standard of care with a grain of salt. For instance, the ISIS practice guidelines are simply a cookbook of practices based in part on the biases of the authors and only loosely on literature that support specific practices. There have not been in most cases comparative studies or placebo controlled studies showing the cookbook methods are any better than any other methods. There was no systemic literature review employed in their creation. Yet the ISIS guidelines are widely touted as standards of care, especially by some of their instructors. They are not. Instead, they represent logical consensus practice patterns that are espoused by one organization to enhance uniformity of conduct of a procedure and possibly enhance safety, yet safety is only enhanced if one recognizes and adjusts for variations in anatomy encountered.

So it is indeed appropriate to view standards, guidelines, best practices, cookbooks in light of who is doing the publishing, whether there is any internal conflict by publishing such guidelines or study (eg. the same organization publishing guidelines offers expensive courses that self servingly teach the procedures in such guidelines), whether the guidelines have broad application or are too specific, and how the guidelines were derived. For specific studies, does the author have any inherent bias to obtain such outcomes (selling a product or runs courses that teach about their specific approach), and is it published in a completely independent journal not controlled or influenced by the author. Only then can we have an intellectual discussion regarding specific merits of such "peer reviewed" literature.

My take is this:

If it isn't listed in Pubmed, the journal by default is not peer reviewed.
Then, if listed in PubMed, is the journal free from or does it minimize bias by appropriate editorial controls. Lax Journal is a farce as he has owned and edited it. The articles paint a rosy picture of epidurals as a panacea for anything that hurts. Experimental and investigational procedures are touted. PMR Journal does the same with US studies in cadavers and small case series telling how US is needed for everything. Same folks who write are all paid by industry to sell machines and do courses. Archives of Internal Medicine is a sham and a total sell out to CAM. They publish acupuncture and chiro studies with conclusions not ven close to the data provided.

The problem is not the peer review, it is the bull getting published and the lack of training on how to identify the craptastic from the useful.

That being said: Rinoo- where you been?

1. Anticoags: Not enough data in the sources to draw definite conclusions. If you suffer the complication, you pay the price.

2. MRI before ESI- we know it is only needed for CYA purposes, not a medical issue, a tort reform issue.

3. Intraspinal cyst: beats me, I've seen 2 in 8 years. My n=2 was that I could get transient relief for 2-3 weeks by draining with 22G. 1 lumbar and 1 cervical. Both did well with surgery. My injections/drainage is as likely placebo as therapeutic.

4. Total dose of steroid: 210mg is nonsense and easy to defend. Monthly injections are more difficult to defend. Injecting 210mg at once is difficult to defend. Once it goes to a lawsuit you have already lost. Outcomes of lawsuits are much less important than just being sued. That's why we have insurance. Same as auto or homeowners. But the NPDB and medical boards could give a flip on outcomes. Your career is is spent preventing getting sued by overusing tests and not treating problems scientifically if it may lead to upset patients. GA is discussing a law that will never happen to end malpractice by forcing arbitration panels. Would be great for us as nothing gets reported and the outcome is decided by experts and not people too stupid to get out of jury duty. But that'll never happen.

 

[Aether2000]

The requirement to be listed in PubMed or National Library of Medicine is that the journal has a large enough circulation and that it abide by Geneva rules adopted for patient safety in clinical studies (ie. IRB). Peer review on the other hand, can mean that the editors of a journal (whether listed in the NLM or not) have vetted and critiqued the article prior to publication after reviewers (also appointed by the journal) have passed the article. It is a very nebulous process, that may be easily derailed from ethical standards, if an editor simply wants something published. The identity of the peer reviewers of an article are not typically published (since that would require them to assume some responsibility for such publication quality). It would be nice for peer review to be more transparent....

Steve hit the nail on the head when he alludes to the usefulness (or not) and quality of a particular article being the real issue... Perhaps we need a review panel to review the published articles giving them movie critic ratings and reviews. Wouldn't that be fun?

 

[Ligament]

Rinoo, welcome back to the board and we invite you to post more often. I think it is wonderful you are on here and honestly we would love to have you involved in the discussions more often.

That said, we do post and discuss literature often here on the forum.

As algosdoc mentions (I'm his biggest fan):

"Peer reviewed does not in any sense mean unbiased or fair. It also does not necessarily reflect the general views held by most pain physicians, a standard of care, nor a work that would stand up in court. "

The quasi-religion of medical study publication is something I try to take with a grain of salt and balance with clinical experience and the experience of my regional peers and yes, the fine physicians on this forum, most of whom are personally familiar with each other (in real life, or "IRL" if you are a forum geek) if you stick around long enough.

As many, if not most, of the contributors to this forum have mentioned, we find this forum to be the most useful source of practical information and idea exchange available, anywhere.

 

[Ducttape]

One of the beauty of the forums is that if someone, say, algos or lobel ( )comes on and goes hoity toity on us, anyone else on the forum can retort and not be seen as a simpleton who did not believe the "expert reviewer", and can (hopefully) meaningfully retort in an esoteric and intelligent manner - although some of us have problems in this front, myself included -- without being shot down as being an ignoramus for not believing "expert" analysis.


in talking to other health care professionals - i.e. nurses and midlevel providers - its interesting to see how many of them take as Gospel when a peer reviewer makes a comment, even if he is farting in his own pants. Case in point, a few years ago i had an interesting discussion with a PA who said that true addiction only exists in chronic pain patients if they are using heroin - otherwise it is pseudoaddiction, and we providers need to increase doses accordingly. His source - a peer reviewed article... (? from members of the APF).

 

[emd123]

My take is this:

If it isn't listed in Pubmed, the journal by default is not peer reviewed.
Then, if listed in PubMed, is the journal free from or does it minimize bias by appropriate editorial controls. Lax Journal is a farce as he has owned and edited it. The articles paint a rosy picture of epidurals as a panacea for anything that hurts. Experimental and investigational procedures are touted. PMR Journal does the same with US studies in cadavers and small case series telling how US is needed for everything. Same folks who write are all paid by industry to sell machines and do courses. Archives of Internal Medicine is a sham and a total sell out to CAM. They publish acupuncture and chiro studies with conclusions not ven close to the data provided.

The problem is not the peer review, it is the bull getting published and the lack of training on how to identify the craptastic from the useful.

That being said: Rinoo- where you been?

1. Anticoags: Not enough data in the sources to draw definite conclusions. If you suffer the complication, you pay the price.

2. MRI before ESI- we know it is only needed for CYA purposes, not a medical issue, a tort reform issue.

3. Intraspinal cyst: beats me, I've seen 2 in 8 years. My n=2 was that I could get transient relief for 2-3 weeks by draining with 22G. 1 lumbar and 1 cervical. Both did well with surgery. My injections/drainage is as likely placebo as therapeutic.

4. Total dose of steroid: 210mg is nonsense and easy to defend. Monthly injections are more difficult to defend. Injecting 210mg at once is difficult to defend. Once it goes to a lawsuit you have already lost. Outcomes of lawsuits are much less important than just being sued. That's why we have insurance. Same as auto or homeowners. But the NPDB and medical boards could give a flip on outcomes. Your career is is spent preventing getting sued by overusing tests and not treating problems scientifically if it may lead to upset patients. GA is discussing a law that will never happen to end malpractice by forcing arbitration panels. Would be great for us as nothing gets reported and the outcome is decided by experts and not people too stupid to get out of jury duty. But that'll never happen.

For instance, an expert witness recently selected 210mg of depomedrol as a yearly maximum dose and touted this as a standard of care because it was published in a peer reviewed journal. Turns out the 210mg/year was a misreading of the original literature based on 4 cases, and published in a journal by an author desperate to pad a fledgling journal with enough articles to keep the journal going.

Yes, especially since the standard dose of methylprednisolone for spinal cord injury is 11,565 mg IV in one day alone (30mg/kg hr 1, and 5.4 mg/kg/hr for 23 hr for a 75kg patient).

Up to 250 mg IV methylprednisolone q 4 hr for corticosteroid response conditions
1mg/kg IV qd for 4 days for aplastic anemia
1000mg IV daily for 3 days for lupus nephritis

Depo-medrol for acute MS exacerbation = 160mg IM daily for 7 days of methylprednisolone then 64 mg IM every other day for 1 month (which is >1800 mg of depo-medrol in 1 month alone)

These are all standard accepted doses (source: Epocrates)

So to argue that 210mg of depo-medrol is a max yearly dose, is well.........you fill in the blank.