President’s Message

NEUBERT 2017As the days grow shorter and the memories of warm summer days fade in the rearview mirror, I have been finding more time to catch up on my reading. I recently completed an interesting article discussing a new book by medical historian Paul A. Offit, titled Pandora’s Lab: Seven Stories of Science Gone Wrong. The author presents an interesting historical perspective on a number of different supposed scientific breakthroughs that ultimately resulted in unintended consequences. A particularly interesting discussion centered on the evolution of the concept of a “heart healthy diet” including the admonition against a diet high in saturated fat in favor of a diet high in unsaturated fat. “Margarine is better than butter” became the well-known mantra despite the fact that the science behind these recommendations was less than solid. An explosion in use of partially hydrogenated vegetable oil and trans fats created an even greater threat to cardiac health. Awareness of this fact began in 1981 when the first reports appeared linking diets high in trans fats to heart disease. On July 10, 2002, the Institute of Medicine issued a report recommending that no amount of trans fat was safe, and recommended an upper intake level of zero. In 2006, the FDA implemented rules requiring manufacturers to list the quantity of trans fats on nutrition labels which has led to a rapid decrease in the use of trans fats. This is a laudable development but untold numbers of people have incurred cardiovascular disease because our purported knowledge led us in the opposite direction of physiologic reality.

Shortly thereafter, and while completing this year’s maintenance of certification reading assignments, I found my previously held notions shaken yet again. An article published in the June issue of the American Journal of Obstetrics and Gynecology evaluating the use of 17-alpha hydroxyprogesterone caproate (17 OHP-C) for the prevention of recurrent preterm birth was reported. This prospective cohort study of 430 women found that weekly injections of 17 OHP-C did not impact the prevention of recurrent preterm birth and was found to lead to a higher rate of gestational diabetes in treated women.

In response to these recent experiences, I began to reflect on other examples of therapies embraced and abandoned when they were proven to be ineffective or downright dangerous. We need to look no further than the use of interventions such as ethanol or magnesium sulfate infusions for tocolysis, terbutaline pumps, and home uterine activity monitoring for examples of promising therapies, widely employed and ultimately abandoned. Finally, one of the most tragic examples in the care of women was the well-intended use of DES with its initially unknown but ultimately disastrous effects.

All of this has led me to think a good deal about a concept that I have come to identify as the uncertainty of certainty. While we endeavor to do what is best for our patients and to use evidence-based medicine to achieve that goal, we must acknowledge that our science is many times imperfect and incomplete. I do not mean to suggest we should abandon the scientific method but rather we must remain diligent and circumspect in our consideration of all of the available evidence as we strive to achieve the prime directive of primum non nocere. Perhaps Lord Byron provided us with the best advice when he said, “In short, I deny nothing, but doubt everything”. We must come to accept the reality that the incontestable knowledge of today may well become the folly of yesteryear.

I believe my notion of the uncertainty of certainty will also underpin much of our November’s meeting presentation on Cultural Competence and Unconscious Bias. Arthur Breese and Antwan Williams will guide us through an exploration of this pervasive phenomenon and help us to understand how it impacts our day-to-day decisions and how we view and interact with those around us. Of special importance is how unconscious bias influences the care of our patients. I hope you will be able to join us for what will be a thought-provoking evening. I look forward to welcoming you!

George Neubert, M.D.