The Bandwagons of Medicine

THE BANDWAGONS OF MEDICINE LAWRENCE COHEN and HENRY ROTHSCHILD* Although medical progress has been extraordinary, its path has often been directed by the overwhelming acceptance of unproved but popular ideas—the bandwagons of medicine. Some of these ideas eventually prove valid, and their uncritical acceptance is belatedly justified. More often, however, they are disproved and abandoned, or replaced by another bandwagon. A new idea can frequently help overcome stagnation and inertia, but unfortunately, an object in motion tends to remain in motion, and the bandwagon becomes an overwhelming force. How do ideas attain acceptance among physicians without rigorous proof of their validity? Moreover, how do valid ideas become extended beyond their proper limitations? The development of a bandwagon is a dynamic process, involving a number of social and scientific factors. A single advocate or group of advocates may be able to generate the interest necessary to launch the idea. Once other investigators become enthusiastic , preconceived notions blur the distinction between quality and quantity of evidence. Clinicians, laymen, the media, and various interest groups all have a role in sustaining unproved ideas. Physicians often accept a new idea because it offers a simple solution to a complex problem . Pressured by their profession to keep abreast of current trends, physicians must absorb an abundance of new material. Therefore, they may read uncritically or concentrate their reading on nontechnicaljournals and abstracts. The public, in search of a panacea, exerts further pressure on the clinician. The mass media give the idea momentum by publishing opinions, conclusions, and extrapolations as data. Research foundations, government agencies, and private industries may each have a vested interest in the idea, endowing it with official sanction and monetary support. Once a hypothesis is generally accepted, further investigation is considered perfidious and is curbed by the reluctance to fund dissidents. Though the idea may become orthodoxy, doubts persist among an unconvinced minority, because the evidence is not conclusive. Eventually *Department of Medicine, Louisiana State University Medical Center, New Orleans, Louisiana 70118.© 1979 by The University of Chicago. 003 1-5982/79/2204-!)062$01.00 Perspectives in Biology and Medicine ¦ Summer 1979 | 531 these doubts lead to a critical réévaluation ofthe hypothesis. The gap left by the decline in popularity of an idea is filled either by a more viable idea or by a newly emerging bandwagon. All sciences are subject to the bandwagon effect, but medicine is particularly susceptible to both the social and scientific determinants. The design and execution of long-term controlled clinical studies are difficult . The evaluation of studies is affected by the subjectivity of both a patient's response and a clinician's interpretation of that response. The data in support of a theory may be unconsciously affected by the selective choice of subjects. Also, the battle against disease is accompanied by a feeling of urgency, a feeling that motivates physicians to endorse new but inadequately tested techniques. Most unfortunately, medical research that questions orthodoxy is restricted by professional ethics. For example, Chalmers et al. [1, p. 1095] stated, in reference to a possible trial of low-dose heparin in the treatment of myocardial infarction: "... the results of the six random control trials reviewed above would make further use of a placebo questionable from an ethical point of view." Because of the pervasiveness of bandwagons, the dynamics of the phenomenon are best seen in examples from various stages of its development . Each past, present, or possible future bandwagon exemplifies a different aspect of the dynamics of the phenomenon. The bandwagon syndrome did not begin with modern medicine. The history ofmedicine is largely the history of this phenomenon; both had roots in the serpent cult of Aesculapius. Often the primary impetus to a bandwagon's development is its identification with a powerful personality . Aesculapius is an extreme example of this identification. Worshipped as the god ofhealing in Roman times, Aesculapius was imported from Greece in the hope of ridding the city ofa plague. In Aesculapius's temples, sacred snakes licked the diseased to effect a cure. His tenets were never questioned by ancient physicians until the cult lost its popularity with the decline of the Roman gods. The scope of a bandwagon is not limited...