A Note to My Younger Colleagues. . .Be Brave
In some ways, our best hope to reveal our follies lies with those new to the field. It is your fresh eyes, unbridled enthusiasm, optimism about what is possible, and commitment to the highest ideals of the profession that can reveal what those who have longer tenure in medicine may have trouble discerning. And yet, to be effective and make use of those insights, you must be brave. Surely, you must also be judicious and prudent in expressing yourself, making sure that your opinions are informed and grounded in science. But when there is an opportunity to speak truth to power, I hope you will consider doing it.
Unfortunately, our profession does not often reward those who question dogma. In fact, there are many episodes throughout the history of medicine and science in which truth was resisted and dogmatic beliefs, however poorly supported by evidence, were imposed by those in a position to do so. If we are to accelerate innovation in medicine, eliminate wasteful practices, and improve the depth and effectiveness of how we care for patients, then there must be room to question traditional approaches and to introduce new and better ways of prevention, diagnosis, and treatment. We are now at that critical juncture.
When I entered medicine, I did not realize that there was such intense pressure to conform. But we learn early on that there is a decorum to medicine, a politeness. A hidden curriculum teaches us not to disturb the status quo. We are trained to defer to authority, not to question it. We depend on powerful individuals and organizations and are taught that success does not often come to those who ask uncomfortable questions or suggest new ways of providing care.
The sense of danger that we feel when we question authority is not unfounded. Those who ask difficult questions or challenge conventional wisdom are often isolated. They may find few opportunities to speak and their writings may not be welcome. Compliance with normative behavior may be forced by fear of recrimination. In some cases, junior faculty may fear that support from mentors will be withdrawn or promotions denied.
I have seen evidence of many such efforts to coerce conformity of opinion and behavior. I have heard of junior faculty who were told that questioning key assumptions of the field, even with evidence, would result in threats to funding and support. I am aware of individuals in nationally prominent organizations whose ability to attain leadership roles was stymied when they raised important questions about organizational strategy, while those who were more compliant progressed. I know individuals whose criticisms of popular products made them the targets of industry efforts to undermine their credibility. I have experienced the exercise of power in the spirit of quieting dissent and debate rather than supporting and encouraging it.
I have grown to appreciate those who will stand up despite the risks or in the face of efforts to silence them. Promoting the best science and the best advocacy for patients and the public sometimes entails risk. Change does not come easily to a system and there is resistance to those who may seek to make the system safer, more effective, and more patient-centered through new ideas or the articulation of uncomfortable truths.
A friend and role model, Victor Montori, who is a faculty member at Mayo Clinic, responded eloquently to a young research fellow who was advised, at an early stage in his training, to avoid a controversy in which he questioned the logic of a prominent study. Montori crystallized the issue in the following e-mail, which he has given me permission to share:
I have struggled with this issue for years. Turns out that this is a common struggle for those who find themselves unable to stay silent in the face of waste, error, low integrity, or abuse.
If you find yourself with some time (not a lot), let me recommend Letters to a Young Contrarian by Hitchens.1 His argument that clarity emerges from conflict is compelling. And for conflict to emerge, ie for clarity to emerge, someone has to take a position. The question you ask is whether this should be you, now, and at this stage of your career.
The threat that if you express your thoughts that this very expression will negatively dispose you to funding and advancement suggests to me that you are receiving advice from folks who choose their battles ‘wisely.' I think one needs to be mindful and respectful and go to battle when important and necessary. Yet, around here, though, people who ask that you choose your battles are indeed expressing fear of conflict. They are often more invested in themselves and their advancement than on the quest for clarity. While I understand their behavior, my personal choice is not to admire it or seek to emulate it.
If you learn by critical analysis and thinking, if you share the results of this thinking with passion and honesty, you will find fertile ground for growth. This may not happen with certain people or in certain places but will happen. You will also attract to your side people who feel strongly about honesty and integrity in science—people worth being around not only because they enjoy the work and do so with passion, honesty, and integrity, but because they will hold you and your work to the same measures of accountability. And guess what? That can only make your work and the world you are trying to change better.
Will your path toward growth be more difficult? Perhaps. Would you have it any other way?
If you take the path toward clarity, I guarantee that you will occasionally find people who will disparage you. They may seek to undermine you, find ways to marginalize you, and try to incriminate you. They may come from directions that surprise you. Powerful ideas often attract attacks that focus more on individuals than ideas. If you raise inconvenient truths or voice uncomfortable opinions, particularly if they threaten someone's comfortable status quo, then you will discover much about the character of those with whom you disagree. But always take the high road, engage in dialogue about ideas and evidence, and be motivated by the opportunity to best serve patients and the public. You will not regret it.
Circulation: Cardiovascular Quality and Outcomes welcomes science that questions conventional wisdom or charts a path toward better care. Our pages commonly have contributions that address, or even cause, controversy. For example, we published a series of opinion pieces about open science in the last issue as part of a call to consider facets of the argument surrounding changing the culture of research.2–5 In the same issue, Hauser and colleagues6 took aim at our current method of postmarketing surveillance of devices and evaluated the utility of an automated safety surveillance system. In a prior issue, Sussman and colleagues7 criticized the national guidelines for aspirin and used strong methods to make a case for a better approach.
Many of our authors raise uncomfortable issues, and we welcome them provided that the science and logic of their arguments are strong and their focus is on the topic rather than the individuals involved. We do not preclude anyone from contributing ideas; we only ask that our authors disclose their relationships that could be perceived as influential. In the end, the best science and arguments should hold sway regardless of who is making them. That person may be someone new to the field or someone with a perceived conflict or someone who is not ordinarily considered an “expert.”
Ultimately, our success as a profession will depend on our ability to engage in debate, acknowledge different opinions, and seek answers through science. The more we depart from the evidence, the more difficult it is to resolve differences. It is critical that we seek truth through science and be humble enough to acknowledge uncertainty. Dogma based on opinion must be reduced from a position of infallibility to one of supposition. For example, only now is the treat-to-cholesterol target dogma of our past prevention guidelines giving way to open discussion surrounding the lack of trial evidence to support the value of intensifying therapy, particularly with nonstatin medications, to achieve targets.8 We must foster a generation of clinical scientists—outcomes researchers and clinicians—who naturally question, in respectful ways, the assumptions of the past.
Defining moments can occur when you least expect them. Are you prepared to respond in a way that will bring honor to you and our profession? If you are prepared to let science lead you to your conclusions, then your work and your ideas will find a venue in these pages. Patient-centered improvement will require such a commitment from all corners of our profession. Be brave.
And let it be noted that there is no more delicate matter to take in hand, nor more dangerous to conduct, nor more doubtful in its success, than to set up as a leader in the introduction of changes. For he who innovates will have for his enemies all those who are well off under the existing order of things, and only the lukewarm supporters in those who might be better off under the new. This lukewarm temper arises partly from the fear of adversaries who have the laws on their side and partly from the incredulity of mankind, who will never admit the merit of anything new, until they have seen it proved by the event.—Machiavelli, 1532
Sources of Funding
Dr Krumholz is supported by grant U01 HL105270-02 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute.
Dr Krumholz is the recipient of a research grant from Medtronic, Inc, through Yale University, and is chair of a cardiac scientific advisory board for UnitedHealth.
The opinions expressed in this article are not necessarily those of the American Heart Association.
- © 2012 American Heart Association, Inc.
- Hitchens C
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