"I've discovered that when a layman tries to cite a medical article, it's usually a BAD one. Kind of like how bad money drives out good, or something. A great example was that one paper about vaccines and autism from Lancet, which was horrible. The authors retracted and disavowed it (after the lead author was found guilty of misconduct), the editor admitted it never should have gotten published, etc., yet it is still cited on all the wingnut websites."
Are you arguing that because I'm a layman every medical article that I cite is a bad one? I've cited a fair number of them, all coming to pretty much the same conclusion. Are they all bad? If so, where are your countervailing good sources to support your argument?
"But I'll grant you this- I've been taught to be very critical of journal articles, so perhaps my suspicious nature colors my outlook. My residency program hit that subject pretty hard. If you're going to be practicing medicine you've got to be able to spot BS. I am definitely capable of going through a paper and deciding if it's a "good" one or not. And, yes, there are a lot of "not good" ones out there. That's the simple truth. I will also grant you this: Ann In Med is a higher-end journal, so probably less garbage, but also certainly not garbage-free."
In one sense, your training has taken this discussion to a higher level, at least as far as concerns me, by forcing me to choose my sources with extra care, knowing I shall have to defend them against a formidable opponent. On the other hand, your self described ability to decide which articles are "good" and which are "not good" troubles me, especially when the subject at hand is one outside of your field of expertise, as you freely admit. I am relieved that you consider Ann In Med to be a higher end journal, which should make articles published by it at least admissible in support of my position.
"A good example- a recent study found that about 30% of recent journal articles were ghost-written. Translation: some drug company or other third party approached a doctor with data about one of their products and offered an honorarium if they'd put their name on it and publish it."
How does that concern our discussion? Do you think the Cuban Government paid some of my sources to write these articles, and the journals cited to publish them? ;0)
"And yet it was published in Ann In Med rather than a public health journal or somesuch. Huh. Stuff like that always makes one wonder. (Trained to be critical- remember?) "
OK, then lets go back to a source I initially cited, which you have ignored so far in this discussion, The American Journal of Public Health. My original citation linked to an abstract, but I will link to the complete article here for your convenience. It seems to this layman to be well written and copiously references a variety of sources, including The New England Journal of Medicine, The WHO, AJPH, Lancet, and a host of others. I will be interested to know your opinion about its contents, as well as whether or not it falls in the garbage category. If it passes muster, I think you will have to admit that it pretty well nails down the connection between the embargo and Cuba's deteriorating health care and nutrition situation in the early 90's, with results which far outlast the date when the embargo restrictions were loosened.
Edited to include link to full article. Another senior moment. Sorry to keep you in suspense, Dean. ;)
"Well, if we're being serious, I'd guess they were Americans, yes. But I think that you are clearly misinterpreting the word "expertise" on this one, Tom. That probably sounds harsh but I'm really not trying to be snide- please listen. Actually, if he used the word "expert" your friend misled you a bit- there is far too much stuff submitted for publication to get the true experts to review it all. On obscure subjects you can usually only produce reviewers who are competent at data analysis, but not experts in the field. One gets to be a reviewer slowly. You publish a few things in a journal yourself. Then that journal asks if you'd like to review someone else's paper, and if so they send you a minor work of little import, and they examine your critiques. Most critiques involve study design or data analysis- that's where a reviewer can shine. (And Barry's paper, frankly, has almost none of either.) For instance, if the reviewer points out that the statistical test used wasn't a valid one for the question asked that pretty much sends the author back to the drawing board. The best critiques involve hard points like that. (As I said, a lot of sloppiness gets sneaked through in the conclusions section, which is more subjective. That's why it is important to review the data presented and not just read the conclusions.) If you produce good critiques the journal starts sending you more important papers to review. "Important" meaning more data-heavy, analytical, and on a timely subject and thus likely to change practice. The editor himself has finite time to go through all of this- unless the paper is important, often reviewer comments are just forwarded to an author to be addressed before re-submission.
Being a reviewer does NOT necessarily mean that you are an Expert on the paper's subject, though you can be, especially if the paper is capital-I Important. For instance, if some paper claimed to overturn the nonoperative management of solid viscus injuries they might well ask Maddox to be a reviewer. There are certainly enough bariatric surgeons out there that they can always have them critiquing articles on that subject, but even then unless the article is very important it probably won't include one of the dozen or so true national bariatric gurus. There are simply too many papers submitted. Hell, I've both published and given presentations at conferences, and believe me I am no particular expert on any of those subjects!"
But Barry's paper DEFINITELY qualifies as one of those "low import" papers on which new reviewers cut their teeth. I mean- there really isn't much in it to review- he just cites some other sources and discusses what they say, and presents some "conclusions." (And, yes, the scare quotes are intentional.) These conclusions are rather subjective- it's not like saying 12% died on antibiotic A and 42% died on antibiotic B, so A must be better. There's no hard data or analysis there. In essence, it's an opinion paper- what we call class 4 or 5 data. See:
For instance, when you read a Cochrane review they always specify what class of evidence their recommendations are based upon. (This is a 5-point scale, with 1 being the best and 5 the worst evidence.) Now, sometimes bad evidence is the only evidence you have, but you should still keeps it's quality in mind. An opinion paper by Maddox probably carries a lot of weight, without better evidence to the contrary. (I admit ignorance as to Barry's standing in this field.)"
I don't dispute any of this as a general description of the shortcomings of the peer review system, even though it is the best thing we have going at present. How could I, as a layman? Still, you haven't shown me any hard data to support your characterization of the Barry article as flawed, and both its data sources and reviewers as being of dubious quality, other than to say that data from Cuban sources is, ipso facto, flawed.
Were someone to write an article about child malnutrition in the US, citing US sources, be similarly flawed, or is US data, by definition, valid? Just curious. Or would this be just another example of American Exceptionalism? ;0)
"Just as in the media, journals occasionally re-visit issues, and I think this paper is an example of that. "Well, it's about time we made it clear that we don't support the Cuban embargo again, eh, fellows?""
I seem to recall you telling me several posts ago that the article could not be construed in any way as reflecting the opinion of the editors of Ann In Med. Have you had a change of heart. ;0)
"And, yes, I'll go out on a limb and suppose that no one who reviews for Ann In Med is going to be terribly familiar with the effects of the Cuban embargo. Papers like this get published for the same reason that papers about war wounds get published in surgical journals- even though high explosive injuries aren't really applicable to civilian practice they are interesting and different, and a nice break from the glut of the usual stuff. Oddly, this means that the reviews tend to be a bit less rigorous, since they want to publish them, for the sake of interest."
That does seem to be going out on a limb a bit, in the absence of supporting evidence.
Off on a tangent, given the increasing incidence violence in this country and the ever more powerful weaponry employed by both the bad guys and the good guys, I should think that the knowledge of how to treat war wounds would be of more than passing interest to trauma surgeons here in the US.
"Whew! Well, I'll calm down a bit now. (The subject of critiquing journal articles always gets me going.) I'm not trying to be totally dismissive of the Barry paper- it is certainly a brick in your argument. I'm really just trying to say that you shouldn't hang your hat on it to the degree that you seem to be. It isn't gospel. And, in fact, it's a poor argument. An argument, yes, but far from your strongest. Honest- it's a fluff piece."
It appears to me to be more a case of you trying to hang my hat on it. If it were the only article I had cited reaching the same conclusion, I would have to agree with you, especially given that I would be presenting it to a medical professional like you. However, I have cited 2 articles from medical journals, one from Amnesty International, one from a Cuban who lived thru the embargo from its beginning up until 2002, one from the president of the EU, one reflecting the near unanimous opinion of the UN General Assembly, including all of our NATO allies and the Scandinavian countries, practically every nation on earth excepting our toady buddies in Israel, Palau and Micronesia, and two abstentions also from the Pacific Island group. In other words, there is near unanimity among the nations of the world. But, just for the heck of it, I'll add 3 more medical sources on PubMed, from a list of 8 hits I got with a layman's simplistic search argument of (Cuban embargo) AND (health care):
"IMO your best argument is the one about residual or continuing effects from when the embargo was much more strict. But, as I mentioned, we need to look at something from economic sources to decide if that's valid. From an admittedly layman's perspective I would propose that if Cuba didn't have mandated asinine economic practices they would have recovered since those stricter versions were stopped."
As I think we have agreed, part of the fault lies with Cuban economic policies. That said, it is nigh impossible to turn an economy around on a dime, especially when the leaders of a country perceive themselves under siege by a superior power bent on their destruction waiting to exploit the disruption. Remember, they had to slowly and painfully convert to the Soviet system of industrial standards for all the bits and pieces of industry, etc, and would have had to reconvert if they were to integrate with the Western economies. It could be done, and doubtless was being done piecemeal as more and more Western nations decided to defy the US and trade with Cuba, but to turn things around completely would take far longer. Then there is the human reality that positions had hardened on both sides, and not all decisions were being made rationally. Speaking of asinine positions, you could as well argue that we should have turned on a dime and dropped the embargo. Had both sides dropped their asinine positions, I have no doubt the Cuban people would be far better off today than they are, and we would have a slightly lower unemployment rate and far stronger moral standing in the eyes of the world.
"Saying that the embargo "forced" Cuba to adopt the Soviets' bankrupt economic system sounds like another weak argument. They chose that economic system."
Given our attempts to strangle their revolution in the crib, what other choice did they have? The Soviets were the only supporter with the muscle to give us pause, and had a system that was viewed at the time by many less developed nations as offering a credible economic alternative to Western style democratic capitalism in parts of the world where issues of economic justice were far more important than freedom of speech, the right to bear arms, and democracy as a system of government. There simply was no other practical alternative. Keep in mind that the fatal flaws in the Soviet system were yet to be laid bare, and by the time they were, the transition to their model was complete.
"They could liberalize today, and their recovery would be swift, even with the current embargo in place. They could have liberalized any time in the past fifty years."
They are liberalizing today, slowly to be sure, given their well founded suspicions about our intentions, but liberalizing nonetheless. As to whether or not they could have liberalized anytime in the past 50 years, well that is highly debatable. We have discussed that subject peripherally here, but to really get into it would require starting another thread, IMO. It is at heart a geopolitical question where economics and health care would play a supporting role instead of being the center of attention, as they have been here.
"Now, what would REALLY be fun would be to switch sides in this debate and see what we could each produce!"
Your setting me up, Dean. Where would I find any sources to support my new position? ;0)