Evidence Supporting Anesthesiology Guidelines: Comment

We have read with great interest the article by Laserna et al.,¹  “Levels of Evidence Supporting the North American and European Perioperative Care Guidelines for Anesthesiologists between 2010 and 2020: A Systematic Review,” in the most recent issue of Anesthesiology. Without a doubt, this is an issue of great importance, and it is imperative to take actions against this problem. On the other hand, it is worth mentioning that this is not a new problem. In 1994 Altman²  mentioned the existence of low-quality medical research in his article “The Scandal of Poor Medical Research,” and a more recent article by Van Calster et al.,³  “Methodology over Metrics: Current Scientific Standards Are a Disservice to Patients and Society,” also takes up this issue, arguing that the main problem is a paradox: “The methodology, the backbone of science, is still too trivialized by the scientific community that finances, undertakes, and informs (pre) clinical research.” Although the methodologic approach is important for the resolution of this problem, we do not believe that it is the only one.

In our opinion, a training approach should be emphasized with three points that should be considered:

1. Stop training “doctors” and focus on training “scientists”: One of the most basic characteristics of science is that scientists assume that the universe we live in follows predictable rules. Scientists theorize using a variety of different reasoning to make new discoveries:

   • a) Inductive: observe a series of events and try to discover a rule that governs the event to extrapolate it and formulate theories of observed and yet to be observed phenomena.

   • b) Abductive: when seeking to propose explanations for events such as unexpected findings.

   • c) Deductive: processes that correspond to the conditions in which a hypothesis can lead to a conclusion or is deductible to it (deductive logic).⁴ 

2. Introduce students to basic science areas: Basic science helps researchers understand systems processes of life. Today more than ever, clinicians need the skills to assess the quality and relevance of the content they are adding to their expanding database of medical knowledge. Therefore, the emphasis of medical education should be on acquiring, interpreting, and applying new knowledge in real scenarios rather than memorizing old (and rapidly obsolete) knowledge; yet, despite the explosion of scientific knowledge in these areas, time spent on teaching basic sciences has been shrinking rather than expanding. Maybe it is time to seriously consider sending students to basic science laboratories. We must recognize that the process of acquiring knowledge is as important, if not more, as the actual knowledge acquired.⁵ 

3. Statistics is also important: Statistical hypothesis testing, although considered a cornerstone in many research areas, has great limitations (such tests are asymmetric—they cannot produce evidence in favor of the null hypothesis, only evidence against it). Further, there are detractors with compelling arguments, such as: “statistical hypothesis testing is widely used but logically indefensible”⁶  or “all age findings of statistical significance are wrong and should be redone.”⁷  Statistical hypothesis testing has survived and has grown in the face of criticism because it meets an important need, yet even if some standard is necessary, it is reasonable to ask whether these tests provide the best standard for medical research. Several alternatives to this problem have been proposed, but two are particularly popular, both of which are “penalized probability criteria”: Akaike’s information criterion and Bayesian information criterion.⁸ 

Although the methodology approach is important in solving this problem, it is not the only one, and it requires a multidisciplinary effort—methodology, statistics, teaching, and basic sciences—with the sole objective of changing the way in which the next generations perceive scientific research in medical areas, thus improving the quality of knowledge creation.

The authors declare no competing interests.