Research in Obstetrics and Gynecology

1
Researchin Obstetrics and Gynecology

• R.A. Pierson, MS PhD
• Professor, Department of Obstetrics, Gynecology
  and Reproductive Sciences
• College of Medicine

2
The Problem
I dont know I dont really care about all
of this research stuff I just want to take
care of patients
Unnamed Ob-Gyn Resident III at OB-GYN Research
Day 2000
3
The Solution
I cant think of a better way for you to care
for your patients than to do research!
Practicing clinician and part-time faculty
member OB-GYN Research Day 2000
4
Training

• To guide or teach something as by subjecting to
  various exercises or experiences
• To guide or control toward a specific goal
• To do exercises that prepare for a specific
  purpose
• To improve or curb by subjecting to discipline

5
Education

• The act or process of acquiring knowledge
• The knowledge or training acquired by this
  process
• The act or process of imparting knowledge
• The theory of teaching or learning

Education implies a continuous process !
6
We need to blend these two concepts into a
coherent whole

• To improve patient care and quality of life
• Imparting the knowledge in our discipline to the
  next generation
• Evaluate the effectiveness of our therapies and
  interventions
• Apply new technologies to old problems
• Create and disseminate new knowledge

7
An Obstetrical Case Study

• Queen Anne was the last Stuart monarch of Great
  Britain.
• In the last 17 years of the 17th Century, she was
  pregnant 18 times.
• Only 5 children were born alive, only 1 of them
  survived infancy.
• He died before reaching adulthood.
• There is no evidence of a genetic disorder
• Queen Anne had the best medical care money could
  buy.

8
What is Research ?

• Research is simply a process by which we answer a
  question using a set of rules called the
  scientific method.

9
The Scientific Method

• Make an observation
• Formulate an hypothesis
• Design an experiment
• Execute the experiment
• Analyze the results
• Draw conclusion
• Formulate a new hypothesis

10
Scientific Method

• In science, we may start with experimental
  results, data, observations, measurements,
  facts.
• We invent a rich array of possible explanations
  and systematically confront each explanation with
  the facts.
• We employ a baloney detection kit which is
  brought out whenever new ideas are offered for
  consideration.
• If the idea survives examination by the tools in
  our kit, we grant it warm, although tentative
  acceptance.

11
Critical Thinking

• The end result of learning the scientific method
• Should reduce biased assertion or uncritical
  acceptance of ideas in the day to day practice of
  obstetrics and gynecology

12

• The fact that an opinion has been widely held is
  no evidence whatsoever that it is not utterly
  absurd.
• Bertrand Russell

13
What is Research ?

• Research is to see what everyone else has seen,
  and to think what no one else has thought.

14
What is Research ?

• Piersons Corollary
• If we knew what we were doing, they wouldnt
  call it research!

15
Hippocrates besides the oath

• Hippocrates of Cos introduced elements of the
  scientific method into the diagnosis of disease
  in the First Century BCE.
• He stressed careful and meticulous observation.
• He recommended that physicians be able to tell,
  from present symptoms alone, the probable past
  and future course of each illness.
• He was willing to admit the limitations of the
  physicians knowledge.

16
Hippocrates Teachings
Leave nothing to chance. Overlook nothing.
Combine contradictory observations. Allow
yourself enough time.
Hippocrates, 1 BCE
17
Medicine in Classical Times

• Although considerable further advances in
  medicine were made in classical times through the
  fall of Rome. What followed in Europe was truly a
  dark age.
• Much knowledge of anatomy and surgery were lost.
  Reliance on prayer and miraculous healing
  abounded. Secular physicians became extinct.
• Chants, potions, horoscopes and amulets were
  widely used.

18
Medicine in Classical Times

• Dissections of cadavers were restricted or
  outlawed, so those who practiced medicine were
  prevented from acquiring firsthand knowledge of
  the human body.
• Medical research and advancement of medical
  knowledge came to a standstill.
• Such is the fruit of Prohibitions.

19
History of Medical Research

• In the revolution of ten centuries, not a single
  discovery was made to exalt the dignity or
  promote the happiness of mankind. Not a single
  idea had been added to the speculative systems of
  antiquity, and a succession of patient disciples
  became in their turn the dogmatic teachers of the
  next servile generation.
• Edward Gibbon, History of the Eastern Empire,

20
With this Papal Bull, Innocent initiated the
systematic accusation, torture and execution of
witches all over Europe. The Inquisition had
begun. Such is the value of authority.
21
What is Science ?

• Science is more than a self-correcting body of
  knowledge it is a way of thinking.
• Science is far from a perfect instrument of
  knowledge it is just the best that we have.
• The scientific way of thinking is at once
  imaginative and disciplined.
• When we are self-indulgent and uncritical, when
  we confuse hopes and facts, we slide into
  pseudo-science and superstition

22
Tenets of Evidence Based Medicine
Everyones clinical opinion counts equally,
regardless of rank or experience. We value
opinions only to the extent that they are
supported by scientific evidence, and not
according to the perceived prestige of the
proponent. When a clinical question arises, we
address it as a group through formal review
rather than by edict from the faculty. To suggest
that more experienced clinicians are inherently
better able to understand science strikes me as
elitist. Science abhors authoritarianism (and has
little use for age discrimination). With
increased age, we tend to expect increased
wisdom however, sometimes, the years bring only
a narrowing of the vision and a hardening of the
arteries. David Grimes, Evidence Based
Medicine, Obstetrics Gynecology 86(3) 1995
23
What is Science ?

• It invites us to let the facts in, even when they
  do not fit our preconceptions.
• It counsels us to carry alternate hypotheses in
  our heads and see which best fit the facts.
• It urges us on a delicate balance between
  no-holds-barred openness to new ideas, however,
  heretical, and the most rigorous skeptical
  scrutiny of everything - new ideas and
  established wisdom.
• This tool is essential for a democracy in an age
  of change.

Carl Sagan, 1996
24
Scientific Illiteracy

• Two recent surveys are interpreted to mean that
  95 of the North American population is
  scientifically illiterate.
• We live in a time where the consequences of
  scientific illiteracy are far more dangerous than
  in any that has come before.
• Real-life examples of scientific illiteracy in
  OB-GYN
• Blood letting in pre-eclampsia
• Twilight Sleep with no regard for the baby

25
Science Precepts

• Every time a scientific paper presents data, it
  is accompanied by an error bar - a quiet, but
  insistent reminder that no knowledge is complete
  or perfect.
• The error bar is a calibration of how much we
  trust what we think we know.
• If the error bars are small, the accuracy of our
  empirical knowledge is high if the error bars
  are large, then so is the uncertainty of our
  knowledge.

26
Science Precepts

• Humans crave absolute certainty they may aspire
  to it they may pretend to have achieved it but
  the history of science tells us that the best
  that we may hope for is successive improvement in
  our knowledge.
• We will always be mired in error. The most each
  generation can hope for is to reduce the error
  bars a little.
• Skepticism is the prime tool in any explorers
  toolkit, if not, we lose our way.

27
Science Precepts

• One of the great commandments of Science is
  Mistrust arguments from authority.
• Authorities must prove their contentions, just
  like everybody else.
• There are no forbidden questions in science, no
  matters too delicate or sensitive to be probed.
• Openness to new ideas, combined with the most
  rigorous, skeptical scrutiny of all ideas, sifts
  the wheat from the chaff. It makes no difference
  how smart, august or beloved you are.

28
Science - Why do we put up with this?

• Do we like to be criticized?
• Every scientist/clinician feels a proprietary
  affection for his or her ideas.
• The hard rule is that if the ideas dont work,
  you throw them away. Dont waste neurons on ideas
  that dont work.
• Devote those neurons to new ideas that better
  explain the data.
• Valid criticism does you a favour.

29

• It is a capital mistake to theorize before one
  has data. Insensibly, one begins to twist facts
  to suit theories, instead of theories to suit
  facts.

Sherlock Holmes in Arthur Conan Doyles A Scandal
in Bohemia, 1891
30
The Tool Kit for Skeptical Thinking

• We will not learn much from mere contemplation.
• How do we decide among competing hypotheses?
• We let experiment do it.
• Control experiments are essential.
• Variables must be separated.
• Often, the experiment must be double blind so
  that those hoping for a certain finding are not
  in the compromising position of evaluating the
  results.

31
What should we do in OB-GYN?

• Be skeptical
• Question authority
• Make observations
• Live and work experimentally
• Draw rational conclusions
• Do not overstate your data

32
Goals

• Open avenues for exploration of the human
  condition
• Well-designed framework within which to work
• Improve reproductive health care for Canadians
  and the global community in all its many meanings
• Understand the impact of our interventions
• On the children born
• On women and their families
• On future generations

33
Goals for Obstetrics Gynecology (and ...ists)

• Foster an integrated research-clinical
  medicine-community approach
• To the creation of new knowledge
• To the provision of clinical services in womens
  health care
• To improving the human condition

34
Truth or Consequences

• The consequences of a lack of research interest
  among physicians are that health purveyors over
  the conduct of research and making health policy.
• e.g., HSURC in Saskatchewan has a goal of
  curtailing clinical practice in some areas
• If we do not do this ourselves, it will be done
  for us

35
Important Points to Be Considered

• Practice of medicine will change with completion
  of the human genome project from a diagnosis and
  treatment model to one of discovery, prevention
  and management of disease.
• We are on the leading edge of a wave of
  incredible discoveries in Reproductive Science
  Medicine.
• Many of these discoveries will challenge some of
  our most closely held beliefs.

36
Important Points to Be Considered

• Reproductive Science Medicine have immense
  medical and social implications
• Enormous strides have been made in maternal
  health and peri-natal care in the developed world
• Reproduction remains a lottery

37
An Eye to the Future.

• Priorities for Reproductive Science and Medicine
  in the next century will be
• to optimize safety of reproduction for mother,
  father and child
• to prevent diseases afflicting the reproductive
  systems,
• to overcome infertility in both sexes, and
• to address the numerous consequences of arrested
  ovarian and testicular function with advancing
  age

38
How Has Our Understanding Changed?
39
Where are We?

• Pills, potions and patches are ubiquitous in
  Obstetrics Gynecology
• The Pill has profoundly changed our concepts of
  reproductive choice
• New choices being developed monthly
• Information is what we try to give our patients

40
Where Would We Be Without It ?
41
Todays research is tomorrows medicine
42
Reproductive Technology

• Simple to say.. More difficult to understand
• Has changed our notions of reproduction
• Progress is highly controversial
• ICSI
• IVM
• In vitro gestation
• Stem cells
• To Clone, or Not to Clone
• Etc.
• WOW.. What a future well have!