Finding Harmony between Science and Art in Pediatric Cardiology: Acknowledging When Being “Objective” May Not Truly Be Objective

As pediatric cardiologists, we greatly value objective decision-making and logic. In fact, it is the physics-driven nature of pediatric cardiology that attracts many professionals to the field. This desire for data-driven decisions becomes even greater based on the degree of severity that patients with congenital malformations of the heart may suffer. This phenomenon manifests itself in both the clinical and academic realms of the field and can often impact the perception of delivered care or conducted research. Because of this, we must explore what our framework of objectivity is, why we strive for increasing the science behind our decisions while minimizing the art in our decisions, and whether or not this maximization of science with minimization of art is truly even helpful. In clinical pediatric cardiology, objectivity is most often synonymous with quantitative measures: laboratory data, oximetry data, hemodynamic data, and vital signs. In research, objectivity is similarly focused around quantitative assessment. Qualitative assessments such as various assessments made by echocardiography, for instance, are often dismissed on the basis of being subjective and replaced by quantitative assessments, which are felt to be more objective. However, the question remains if quantitative measures are always truly better than qualitative measures? For instance, is measuring the vena contracta of a regurgitant jet by echocardiography truly more accurate than an experienced echocardiographer grading the degree of insufficiency? Can we be entirely certain the narrowest portion is indeed in the plane of imaging that they are using? Can this even be achieved without obtaining a true three-dimensional reconstruction that can be interrogated in the infinite number of planes that are present? Can we be entirely certain that other fluid jets aren’t impacting the so-called vena contracta? Another example lies in the concept of assessing left ventricular function. Those who have performed echocardiograms are well aware that shortening the fraction and ejection fraction can change significantly with subtle changes in the actual tracing of the ventricular boundary on the echocardiographic imaging. Tracings can appear to reasonably and equally approximate these boundaries, but can produce values that fall on either side of the cutpoint that is defined as normal. Not to mention that these cutpoints are human-defined and prone to error in our own understanding and are also the product of human-developed statistics. So then why do we insist that the decision to shorten fraction and ejection fraction is more reasonable than qualitative assessments of function by an experienced echocardiographer? Quantitative measures, even those that are accurately reproducible, are dependent upon human interpretation, which, itself depends upon the health-care providers’ understanding of statistics, and is thus limited by their level of statistical expertise or understanding. Additionally, normal values are determined by their value’s position inside a specific range that contains a majority of data points. The number of data points, be it 92.5%, 95%, or 97.5%, is often arbitrarily selected by researchers who have decided that a certain percentage of values are abnormal based on just the fact that they fall in a certain tail area of a distribution. This can present a particular selection bias since, when it comes to interpreting research manuscripts, many fail to understand what p-values actually are. The p-value