Research in Obstetrics and Gynecology

1. Researchin Obstetrics and Gynecology R.A. Pierson, MS PhD Professor, Department of Obstetrics, Gynecology and Reproductive Sciences College of Medicine

2. The Problem “I don’t know…” “I don’t really care about all of this research stuff…” “I just want to take care of patients…” Unnamed Ob-Gyn Resident III at OB-GYN Research Day 2000

3. The Solution “I can’t think of a better way for you to care for your patients than to do research!” Practicing clinician and part-time faculty member OB-GYN Research Day 2000

4. Training • To guide or teach something as by subjecting to various exercises or experiences • To guide or control toward a specific goal • To do exercises that prepare for a specific purpose • To improve or curb by subjecting to discipline

5. Education • The act or process of acquiring knowledge • The knowledge or training acquired by this process • The act or process of imparting knowledge • The theory of teaching or learning Education implies a continuous process !

6. We need to blend these two concepts into a coherent whole • To improve patient care and quality of life • Imparting the knowledge in our discipline to the next generation • Evaluate the effectiveness of our therapies and interventions • Apply new technologies to old problems • Create and disseminate new knowledge

7. An Obstetrical Case Study • Queen Anne was the last Stuart monarch of Great Britain. • In the last 17 years of the 17th Century, she was pregnant 18 times. • Only 5 children were born alive, only 1 of them survived infancy. • He died before reaching adulthood. • There is no evidence of a genetic disorder • Queen Anne had the best medical care money could buy.

8. What is Research ? • Research is simply a process by which we answer a question using a set of rules called the scientific method.

9. The Scientific Method • Make an observation • Formulate an hypothesis • Design an experiment • Execute the experiment • Analyze the results • Draw conclusion • Formulate a new hypothesis

10. Scientific Method • In science, we may start with experimental results, data, observations, measurements, “facts”. • We invent a rich array of possible explanations and systematically confront each explanation with the facts. • We employ a “baloney detection kit” which is brought out whenever new ideas are offered for consideration. • If the idea survives examination by the tools in our kit, we grant it warm, although tentative acceptance.

11. Critical Thinking • The end result of learning the scientific method • Should reduce biased assertion or uncritical acceptance of ideas in the day to day practice of obstetrics and gynecology

12. The fact that an opinion has been widely held is no evidence whatsoever that it is not utterly absurd. Bertrand Russell

13. What is Research ? • Research is to see what everyone else has seen, and to think what no one else has thought.

14. What is Research ? Pierson’s Corollary If we knew what we were doing, they wouldn’t call it research!

15. Hippocrates ~ besides the oath • Hippocrates of Cos introduced elements of the scientific method into the diagnosis of disease in the First Century BCE. • He stressed careful and meticulous observation. • He recommended that physicians be able to tell, from present symptoms alone, the probable past and future course of each illness. • He was willing to admit the limitations of the physician’s knowledge.

16. Hippocrates’ Teachings “Leave nothing to chance.” “Overlook nothing.” “Combine contradictory observations.” “Allow yourself enough time.” Hippocrates, 1 BCE

17. Medicine in Classical Times • Although considerable further advances in medicine were made in classical times through the fall of Rome. What followed in Europe was truly a dark age. • Much knowledge of anatomy and surgery were lost. Reliance on prayer and miraculous healing abounded. Secular physicians became extinct. • Chants, potions, horoscopes and amulets were widely used.

18. Medicine in Classical Times • Dissections of cadavers were restricted or outlawed, so those who practiced medicine were prevented from acquiring firsthand knowledge of the human body. • Medical research and advancement of medical knowledge came to a standstill. • Such is the fruit of “Prohibitions”.

19. History of Medical Research In the revolution of ten centuries, not a single discovery was made to exalt the dignity or promote the happiness of mankind. Not a single idea had been added to the speculative systems of antiquity, and a succession of patient disciples became in their turn the dogmatic teachers of the next servile generation. Edward Gibbon, History of the Eastern Empire,

20. It has come to our ears that members of both sexes do not avoid to have intercourse with evil angels, incubi, and succubi, and that by their sorceries, and by their incantations, charms and conjurations, they suffocate, extinguish, and cause to perish the births of women. Pope Innocent VIII Papal Bull, 1484 With this Papal Bull, Innocent initiated the systematic accusation, torture and execution of “witches” all over Europe. The Inquisition had begun. Such is the value of “authority.”

21. What is Science ? • Science is more than a self-correcting body of knowledge; it is a way of thinking. • Science is far from a perfect instrument of knowledge; it is just the best that we have. • The scientific way of thinking is at once imaginative and disciplined. • When we are self-indulgent and uncritical, when we confuse hopes and facts, we slide into pseudo-science and superstition

22. Tenets of Evidence Based Medicine “Everyone’s clinical opinion counts equally, regardless of rank or experience. We value opinions only to the extent that they are supported by scientific evidence, and not according to the perceived prestige of the proponent. When a clinical question arises, we address it as a group through formal review rather than by edict from the faculty. To suggest that more experienced clinicians are inherently better able to understand science strikes me as elitist. Science abhors authoritarianism (and has little use for age discrimination). With increased age, we tend to expect increased wisdom; however, sometimes, the years bring only a narrowing of the vision and a hardening of the arteries.” David Grimes, Evidence Based Medicine, Obstetrics & Gynecology 86(3) 1995

23. What is Science ? • It invites us to let the facts in, even when they do not fit our preconceptions. • It counsels us to carry alternate hypotheses in our heads and see which best fit the facts. • It urges us on a delicate balance between no-holds-barred openness to new ideas, however, heretical, and the most rigorous skeptical scrutiny of everything - new ideas and established wisdom. • This tool is essential for a democracy in an age of change. Carl Sagan, 1996

24. Scientific Illiteracy • Two recent surveys are interpreted to mean that 95% of the North American population is scientifically illiterate. • We live in a time where the consequences of scientific illiteracy are far more dangerous than in any that has come before. • Real-life examples of scientific illiteracy in OB-GYN • Blood letting in pre-eclampsia • “Twilight Sleep” with no regard for the baby

25. Science Precepts • Every time a scientific paper presents data, it is accompanied by an error bar - a quiet, but insistent reminder that no knowledge is complete or perfect. • The error bar is a calibration of how much we trust what we think we know. • If the error bars are small, the accuracy of our empirical knowledge is high; if the error bars are large, then so is the uncertainty of our knowledge.

26. Science Precepts • Humans crave absolute certainty; they may aspire to it; they may pretend to have achieved it; but the history of science tells us that the best that we may hope for is successive improvement in our knowledge. • We will always be mired in error. The most each generation can hope for is to reduce the error bars a little. • Skepticism is the prime tool in any explorer’s toolkit, if not, we lose our way.

27. Science Precepts • One of the great commandments of Science is “Mistrust arguments from authority.” • Authorities must prove their contentions, just like everybody else. • There are no forbidden questions in science, no matters too delicate or sensitive to be probed. • Openness to new ideas, combined with the most rigorous, skeptical scrutiny of all ideas, sifts the wheat from the chaff. It makes no difference how smart, august or beloved you are.

28. Science - Why do we put up with this? • Do we like to be criticized? • Every scientist/clinician feels a proprietary affection for his or her ideas. • The hard rule is that if the ideas don’t work, you throw them away. Don’t waste neurons on ideas that don’t work. • Devote those neurons to new ideas that better explain the data. • Valid criticism does you a favour.

29. It is a capital mistake to theorize before one has data. Insensibly, one begins to twist facts to suit theories, instead of theories to suit facts. Sherlock Holmes in Arthur Conan Doyle’s A Scandal in Bohemia, 1891

30. The Tool Kit for Skeptical Thinking • We will not learn much from mere contemplation. • How do we decide among competing hypotheses? • We let experiment do it. • Control experiments are essential. • Variables must be separated. • Often, the experiment must be double blind so that those hoping for a certain finding are not in the compromising position of evaluating the results.

31. What should we do in OB-GYN? • Be skeptical • Question authority • Make observations • Live and work experimentally • Draw rational conclusions • Do not overstate your data

32. Goals • Open avenues for exploration of the human condition • Well-designed framework within which to work • Improve reproductive health care for Canadians and the global community in all its many meanings • Understand the impact of our interventions • On the children born • On women and their families • On future generations

33. Goals for Obstetrics & Gynecology (and ...ists) • Foster an integrated research-clinical medicine-community approach • To the creation of new knowledge • To the provision of clinical services in women’s health care • To improving the human condition

34. Truth or Consequences • The consequences of a lack of research interest among physicians are that health purveyors over the conduct of research and making health policy. • e.g., HSURC in Saskatchewan has a goal of curtailing clinical practice in some areas • If we do not do this ourselves, it will be done for us

35. Important Points to Be Considered • Practice of medicine will change with completion of the human genome project from a diagnosis and treatment model to one of discovery, prevention and management of disease. • We are on the leading edge of a wave of incredible discoveries in Reproductive Science & Medicine. • Many of these discoveries will challenge some of our most closely held beliefs.

36. Important Points to Be Considered • Reproductive Science & Medicine have immense medical and social implications • Enormous strides have been made in maternal health and peri-natal care in the developed world • Reproduction remains a lottery

37. An Eye to the Future…. • Priorities for Reproductive Science and Medicine in the next century will be • to optimize safety of reproduction for mother, father and child • to prevent diseases afflicting the reproductive systems, • to overcome infertility in both sexes, and • to address the numerous consequences of arrested ovarian and testicular function with advancing age

38. How Has Our Understanding Changed?

39. Where are We? • Pills, potions and patches are ubiquitous in Obstetrics & Gynecology • “The Pill” has profoundly changed our concepts of reproductive choice • New choices being developed monthly • Information is what we try to give our patients

40. Where Would We Be Without It ?

41. Today’s research is tomorrow’s medicine

42. Reproductive Technology • Simple to say.. More difficult to understand • Has changed our notions of reproduction • “Progress” is highly controversial • ICSI • IVM • In vitro gestation • Stem cells • To Clone, or Not to Clone • Etc…. • WOW.. What a future we’ll have…!