By R Carter
In healthcare research there are 4 basic types of publications for representing the types of medical research which are done. Some types are more reliable than others and have stricter controls for interpreting results. Some are intended for public consumption and others are not. Some are designed to eliminate bias while others invite and even encourage it. Knowing the difference is critical to understanding the weight which should be assigned to research articles published for public consumption and in evaluating regulations used by government agencies for healthcare policy which affects millions of Americans.
This is the most common type of journal manuscript and represents the most thorough type of investigative research, designed to uncover new truths in the field of medicine. Such research includes strict controls designed to eliminate individual or personal bias when interpreting the data. They include control groups (a single blind study) where individuals in the study don’t know if they are full participants in the experiment or not, they may in fact be receiving a placebo. In a double blind study a single blind control group exists plus, the testers conducting the experiment or interpreting the data are also blind to which individuals are in the placebo group and which are in the experimental group. The testers are then free to interpret the test results free of any personal bias which would alter the interpretation of the data.
Original research is used to publish full reports of data from the research. In publications it may be called an Original Article, Research Article, Research, or just Article, depending on the journal. The Original Research format is suitable for many different fields and different types of studies. The published research includes full Introduction, Methods, Results, and a Discussion sections.
Short reports or Letters:
These are papers which communicate brief reports or preliminary findings of data from original research that editors believe will be interesting to many researchers, and that will likely stimulate further research in the field. It should be noted that these types of publications are intended for other research professionals and members of the healthcare community, they are not designed for public consumption as they require a background in the science and disciplines for which they are written. Furthermore as the findings published are often preliminary, they offer no definitive conclusions on the results and outcomes.
Since they have a relatively short format they are useful for scientists, and include results that are time sensitive. This format often has strict length limits, so some experimental details not usually published until the authors write a full Original Research manuscript. These papers are also sometimes called Briefs or Brief Communications.
Review Articles provide a comprehensive summary of research on a certain topic, and a perspective on the state of the field and where it is heading. They are often written by leaders in a particular discipline after invitation from the editors of a journal. The types of reviews published by a journal often reflect a bias held by the publishers and as such, publishers often reveal an agenda for the issues they publish on. Reviews are often widely read (for example, by researchers looking for a full introduction to a field) and highly cited. Reviews commonly cite approximately 100 primary research articles.
Review Articles invite and encourage opinions from the experts who are doing the review and are the format most often used to criticize the original research of others. Such criticisms both pro and con represent the views of the author and can’t be construed as unbiased in the highly competitive field of medical research. As such the audiences for such reviews are other researchers and healthcare professionals because interpreting an opinion requires a background in the science and discipline of the subject matter.
A review article is in essence and editorial and the author is under no obligation to repeat the experiment of the original researcher, relying solely on their expertise in the field as the basis for their opinion. The purpose of a review article is to sway opinions or influence others and is therefore not necessarily fit for public consumption. Despite these shortcomings, review articles are more widely circulated to the general public than original research, appearing in public media more so than original research.
These are articles which report specific instances of interesting phenomena. A goal of Case Studies is to make other researchers aware of the possibility that a specific phenomenon might occur, they by no means imply a standard for all similar situations. This type of study is often used in medicine to report the occurrence of previously unknown or emerging pathologies.
Case Studies involve small groups, usually less than 10,000 individuals, are limited to a single setting or a group of settings in a small geographical area such as clinics or hospitals within one or two states. More often than not, such studies address a single clinical setting involving a few hundred individuals.
Case Studies do not involve control groups, but simply report findings based on selection criteria for a group in a setting. A case study may, but often does not include, original data, but is a retrospective study done on data collected by other groups. The source data may be medical records from one or more clinical settings or could be based on claims filed which include coded diagnosis data, treatments and demographic information.
Terms often used are Cohort Studies, meaning a group of people in a specific setting and is a type of medical research used to investigate the causes of disease and to establish links between risk factors and health outcomes. They are intended to be informational only, information which can lead researchers to investigate a phenomena more thoroughly and do not constitute definitive wide spread trends. Yet these types of research tend to garnish more headlines than Original Research which uses empirical data and control methods.
The Goal of Medical Research:
Medical research is part of the evidence gathering process in forming public policy for healthcare. Government uses this evidence based system to collect data, interpret it and formulate policy initiatives to correct a problem. Policy making includes numerous individuals, corporations, non-profit organizations and interest groups which compete and collaborate to influence policymakers to act in a particular way. For this reason, policy making is a political effort and subject to the same pressures of power, influences and money that any other political effort does. Government policy therefore often reflects only the views of those involved in the debate and provides outcomes which only benefit one group at the expense of another.
Although the stated role of Government is to strike a balance between disparate groups, without equal representation of all affected parties, Government is often compelled to act due to the nature of a problem and do so despite unequal representation. When an opposing group has no seat at the table, the debate is often skewed towards the groups who do have a seat.
It should be noted that Government holds a legal monopoly to initiate or threaten physical and monetary force to achieve its ends. Public policy therefore is a dynamic, complex, and interactive system through which public problems are identified and countered by special interest groups who have a vested interest in the outcomes of policy decisions. Those who fail to engage in such policy debates, forfeit their views to those who do, the outcome often being regulations which carry the force of law which has not been vetted by our elected officials.
What constitutes good research?
For research to be meaningful enough to justify changes in how healthcare is delivered to the public, certain criteria should be met. The best sources of empirical data comes from Original Research yet this is often not the source which influences policy, review articles often weigh heavy in policy making decisions. Still, the research must be peer reviewed, that is it should be repeated by multiple independent groups, using the same or slightly altered methods and reviewed by experts in the specific field of study to form a consensus on the reliability of the data and its interpreted meaning. To best represent the whole of society, studies should be done on hundreds of thousands of individuals across multiple geographic locations. When a national crisis has been declared, less reliable sources of research are used to expedite the policy making process.
Interpretation of the results is only as good as the methods used to collect it and by the types of individuals used to interpret it. In America, the National Institute of Health has an annual budget of around $30 Billion for medical research to meet this requirement. But funding for research can be as politically motivated as the policy making process for public health regulation. In the absence of large scale medical research, public policy for healthcare suffers the bias of a rush to judgement leading to disparities and unequal access to healthcare and funding for minority groups.
The interpretation process is often a critical point where undue influence can alter the outcomes of public policy. Take for example the current debate around the opioid crisis, the problem was seen as so severe that government agencies often enlisted expert individuals who misapplied an interpretation of the data to multiple segments or groups of people, i.e. the 2016 CDC Guidelines for Chronic Pain Management. In the rush to counter a problem the agency failed to enlist a more diverse group of medical experts, leading to government policy that endangered lives, some with the loss of quality of life, unemployment and an increase in suicides due to forced tapering and termination of medical care.
Further complicating this action was the fact that declaring a national health crisis affords policy makers the right to forego the usual methods of data collection and interpretation, taking action based on what little information existed at the time in an effort to thwart a problem. It’s in this type of an environment that the opioid crisis took its roots and has led to the wide scale discrimination of chronic pain patients.
Changing the Debate
In the area of healthcare, experts are not always the only source which needs to be heard. Without a firm grasp of the diversity of those impacted by the subject and the outcomes which impact them, only the problem is defined and the correct solutions are often obscured by the details which define the problem. The latter often leads to a rush to judgement which produces collateral damage which was unanticipated; this is a fact that is now well recognized in the wake of the opioid crisis.
Mass communications and technological changes such as the widespread availability of the Internet have caused the public policy system to become more complex and interconnected. The changes pose new challenges to the current public policy systems and pressures leaders to evolve to remain effective and efficient. At the same time such changes offer mechanisms for those less empowered financially and by connections to those who do have influence, to raise public awareness to all pertinent points of view. The internet has been a boom for these groups, allowing them to have a public voice when denied a seat at the table on policy matters. Such grass root efforts can turn the tide in public policy as long as free speech is allowed and censorship is absent from the process.
Hundreds of small groups have emerged in the wake of the opioid crisis to draw attention to the failure of Government to carry out its duty and responsibility of providing a voice to all points of view. More specifically to make a distinction between opioid abuse and the medical use of opioids in treating pain. And while small gains being made, opposing the view of lumping chronic pain patients with opioid abusers has failed to gain the national recognition needed to affect relevant changes for how our national healthcare policy addresses these two disparate groups.
Until these diverse groups unite into a single voice, with financial backing and political connections to those who can affect a change in policy, they will remain a silent minority in the national debate. For example, as of July 2019 the political race for the 2020 presidential election has begun, yet no candidate so far has a platform for addressing the differences between chronic pain patients treated with opioid verses opioid abusers. The tragedies facing the chronic pain community remain an issue hidden from public sight.
With an estimated twenty million Americans now tapered down or terminated off of pain medication, medication which was used to remain employed as productive members of society, as members who paid into the system rather than drawing from it, our current national policy on restricting access to opioids to those with legitimate medical need, creates a new class of disenfranchised citizen. And all of this collateral damage for the sake of addressing a problem which only affects two million Americans, these numbers seem disproportionate, making the cure worse than the disease.
For the thousands who have died and the millions who remain jobless, house bound and bedridden, we owe it to these to unite with a common voice and single political objective of turning the tide in the rush to judgment which has discriminated against so many.