Why Consensus-Based Thinking Holds Back Science
By: Nita Jain
Tags: Ideas, Science, Innovation, Education, Health

In my experience, even after multiple hospitalizations and countless appointments with specialists, mainstream Western medicine couldn’t fix what ailed me. The general approach to distract and entertain the patient and throw some drugs at the problem while nature heals the body sometimes works for acute conditions but often breaks down in the face of more deeply-rooted chronic health issues.

Jain mentioned two distinct camps of thought that existed when it came to neuroscience and medicine at large — the biochemical, molecular model camp and the complementary medicine camp. Her discussion of the divide between modern and alternative medicine got me thinking about how the use of these terms is problematic at a much larger level. Oftentimes, an alternative therapy will emerge as a more successful treatment than the current standard of care, but a substantial window of time typically elapses before that alternative treatment migrates to default status, if it ever does. Let me give an example.

The current standard of care for recurrent Clostridioides difficile infection (rCDI) is antibiotic treatment, while fecal microbiota transplantation (FMT) is regarded as an “alternative” or experimental treatment. In a randomized controlled trial of 64 patients, administration of FMT, Fidaxomicin, or Vancomycin for the treatment of rCDI yielded remission rates of 92%, 42%, and 19%, respectively. In a larger study involving almost 300 patients, FMT outperformed antibiotics when evaluating several different outcomes in rCDI patients. Compared to antibiotic recipients, FMT recipients had a much lower incidence of bloodstream infection (BSI) in the 90 days following treatment (4% vs. 26%). Among those who suffered bloodstream infections, 12% in the antibiotic group develop fungal BSI while none in the FMT group developed fungal BSI.

Illustration of C. difficile bacteria by Kateryna_Kon on Adobe Stock

Additionally, FMT recipients had an average hospital stay that was 14 days fewer than those in the antibiotics group. Finally, FMT recipients also enjoyed a significantly higher overall survival rate (89% vs. 58%). Out of 58 patients who died within 30 days of receiving treatment, 5 were FMT recipients and 53 were antibiotic recipients.

All study designs are subject to certain limitations, of course. The first study mentioned had a small sample size while the second was nonrandomized and thereby may have been subject to some confounding effects. Nonetheless, both immediate outcomes, in terms of clinical resolution, and long-term outcomes, in terms of hospitalization duration, mortality, and overall survival, favor FMT therapy over antibiotics for recurrent C. difficile infection. Yet antibiotics remain the standard of care.

As illustrated above, in some cases, the assumption that alternative therapies necessarily equate to quackery is at odds with empirical evidence. Herein lies the problem. All medicine not currently accepted as mainstream is currently classified as complementary and alternative medicine (CAM), and this latter camp is often dismissed altogether as sham medicine, analogous to throwing the baby out with the bath water. For the record, both camps are fallible, and “natural” is not always synonymous with “safe.” When evaluating any given treatment method, it is best to rely on the quality of evidence available rather than credentials or claims of authority.

Neither alternative nor mainstream medicine has a perfect track record. When we consider how much time passed before the scientific consensus acknowledged a causal link between smoking and lung cancer or the dangers of lead in consumer products, we may take care to approach the subject of medical safety and efficacy with more humility moving forward.

In the 1950s, thalidomide was introduced with the guarantee that it could be “given with complete safety to pregnant women and nursing mothers without any adverse effect on mother and child,” but use of this drug resulted in over 90,000 miscarriages and 10,000 children having been born with severe deformities. In modern times, we should realize that we are still subject to the same fallibility as previous decades. Orthodox medicine is not always safe or effective, and the same can be said of alternatives.

That being said, combining the strengths of various camps can lead to more innovative discoveries and effective treatments and can maybe even mitigate some the risks associated with each camp individually. For example, artemisinin, a natural compound extracted from sweet wormwood, is an effective herbal remedy for malaria, especially when used in conjunction with other pharmacological agents.

Applying scientific rigor to ancient wisdom can also yield novel insights into disease mechanisms and treatments. When we resist the tendency to compartmentalize knowledge into separate groups and integrate our knowledge instead, we may uncover unexpected insights. Allow me to regale you with the story of a plant pathologist-turned-microbiologist who used traditional Chinese medicine to help elucidate the link between obesity and the gut microbiome.

Zhao Liping began his scientific career after earning his Ph.D. in molecular plant pathology from Nanjing Agricultural University. When he started his own lab in 1990, he primarily focused on the use of beneficial bacteria to control plant pathogens. By the time he finished his postdoctoral fellowship at Cornell and returned to China in 1995, he weighed a corpulent 90 kilograms (~198 lbs), and his health had significantly deteriorated.

Photo by Lothar Bodingbauer on Unsplash

The traditional weight loss approach advocated by Western literature of calorie restriction and strenuous exercise didn’t make much sense to him.

“Nutritionally, your body is under stress,” he explains. “Then you add to that physical stress. Maybe you can lose weight, but you might also damage your health.”

In 2004, after coming across a paper on the link between obesity and the gut microbiota in mice by Jeffrey Gordon, a microbiologist at Washington University School of Medicine in St. Louis, Missouri, Zhao changed his career trajectory — and improved his quality of life. He started digging through traditional Chinese medicine literature for further inspiration and began a food regimen that included Chinese yam and bitter melon, fermented prebiotic foods thought to encourage the growth of metabolically beneficial microbes in the digestive tract.

As a result of these dietary modifications, in two years, Zhao lost 20 kilograms (44 lbs), which was also accompanied by a reduction in blood pressure and heart rate. His gut microbiota also underwent considerable transformation, as Faecalibacterium prausnitzii — a bacterium associated with anti-inflammatory effects — flourished from undetectable levels to 14.5% of his gut bacteria. These changes persuaded him to critically study the role of the microbiome in obesity and metabolic health. He began with mice and shortly after attempted to translate his findings to humans.

In 2009, Zhao started his first clinical trial in which he enrolled 123 clinically obese volunteers who underwent a 9-week tailored program similar to the one he had prescribed for himself. During the study, Zhao maintained records of both metabolic measurements and gut microbiome changes and found that his volunteers displayed similar positive shifts in microbial composition and inflammation reduction as those he had observed in himself. Encouraged by the results, Zhao began trials in three additional Chinese cities, enrolling a total of more than 1000 patients.

American geneticist and microbiologist George Weinstock describes Zhao’s work as “Western reductionist science meets traditional Chinese medicine.” Indeed, by bridging two worlds and integrating different ways of thinking, Zhao was able to demonstrate how gut microbiota modulation as a result of dietary intervention can simultaneously “enhance the intestinal barrier integrity, reduce circulating antigen load, and ultimately ameliorate the inflammation and metabolic phenotypes.” Perhaps more importantly, Zhao successfully improved not only his own metabolic health but also the health of countless others through his perseverance, resourcefulness, and willingness to be open-minded.

Robin Warren (left) and Barry Marshall walk to a press conference at the University of Western Australia after winning the 2005 Nobel Prize in Physiology or Medicine (Credit: Tony Ashby/AFP/GETTY)

The limitations surrounding compartmentalized thinking also highlight the problem of equating consensus dogma with efficacy, which may deprive some patients of potential benefits and subject others to avoidable harm. For one, scientific and medical consensus changes over time. Thanks to the observations of Copernicus, Kepler, and Galileo, astronomers and society at large eventually shifted from a geocentric view of the universe to a heliocentric one. Barry Marshall and Robin Warren discovered the bacterium Helicobacter pylori and elucidated its role in gastritis and peptic ulcer disease, upending the notion that excessive stomach acid was to blame as well as the assumption that bacteria could not survive the harsh conditions of the human stomach (H. pylori neutralizes stomach acid in its environment by producing an enzyme called urease that breaks down urea into ammonia and carbonic acid, thereby raising intestinal pH). Marshall even went so far as to infect himself with H. pylori to demonstrate its causative role in the development of gastritis, satisfying two of Koch’s postulates in the process and hinting at the untapped potential utility of n-of-1 studies. As a result of this landmark discovery in 1982, a once widespread surgical procedure became a relative rarity, and Marshall’s experiments spurred further investigation into microbes as causative or contributing agents in other disease conditions.

Second, scientific consensus is often unduly influenced by special interests. Contrary to the narrative of Marshall’s contributions, this is a story about how a medical procedure became commonplace despite a lack of evidence showing any demonstrable health effects. For decades, angina, or chest pain, in patients with coronary artery disease (CAD) has been treated by inserting a mesh tube or stent into arteries supplying blood to the heart in order to keep blood vessels open and increase circulation, theoretically addressing the problem. Stents can be life-saving devices for individuals in the throes of a heart attack, but cardiologists observed that stable patients who underwent this procedure also reported improved symptoms. Consequently, the procedure by which stents are inserted, percutaneous coronary intervention (PCI), became more widely adopted for use in stable patients who have blocked arteries and may or may not also experience chest pain upon exertion.

Stent implantation into blood vessels for circulatory support by Christoph Burgstedt on Adobe Stock

But emerging evidence has cast scrutiny on this commonly practiced medical procedure. A clinical trial published in the New England Journal of Medicine in 2007 examined the efficacy of stents on the endpoints of heart attacks and deaths in almost 2,300 patients with confirmed coronary artery disease. Patients were randomly assigned to receive either PCI with medical therapy or medical therapy alone. After an average follow-up period of five years, PCI was not found to reduce the risk of all-cause mortality, heart attacks, or other major cardiovascular events when used as an adjunct to medical therapy. Similarly, a 2012 meta-analysis in JAMA Internal Medicine collected the results of eight different studies and concluded that stent implantation conferred no benefits for the prevention of heart attacks, death, or angina in patients with stable coronary artery disease.

Nonetheless, the use of coronary stents is still widespread despite evidence that the installation of these tiny wire cages may be no more useful than sham surgery. In 2017, researchers from Imperial College London conducted a double-blinded study (ORBITA) in which 200 CAD patients were randomized to receive either PCI or a placebo procedure in which a catheter was threaded up to the blocked artery but no stent was inserted. While stents did improve blood flow in the patients who received them, no discernible difference in exercise capacity was observed between the two groups. This finding may be due to the fact that collateral circulation often makes up for the blood supply deficit induced by any one blockage site. While there may not be enough positive evidence to justify the risks associated with PCI, stent insertion remains a profitable procedure, costing anywhere between $11,000 and $41,000 in United States hospitals.

Third, as humans, we are highly susceptible to certain biases and heuristics, including groupthink, a term coined by psychologist Irving Janis in 1971 to describe a situation whereby “a group of well-intentioned people make irrational or non-optimal decisions spurred by the urge to conform or the discouragement of dissent.” We often also fall prey to the illusory truth effect, first identified in a 1977 study at Villanova and Temple University. This psychological phenomenon describes the tendency to equate repeated information with fact and may explain why myths such as the one that “humans only use 10% of their brains” are widely circulated and accepted despite substantial evidence proving this statement false.

Photo by Fachy Marín on Unsplash

Overall, substituting compartmentalized and consensus-based thinking for integrative and evidence-based thinking will allow for more innovative discoveries and creative solutions and may even end up improving your health and overall quality of life.