MIETTINEN OS: ON EXCELLENCE OF EPIDEMIOLOGIC ACADEMIA

Transcription

1 Nobel Forum, 23 February 2018 MIETTINEN OS: ON EXCELLENCE OF EPIDEMIOLOGIC ACADEMIA With Special Reference to the Karolinska Institute The proceedings in, and related to, this session will be as follows: 1. The format of this session will be one of a relatively brief lecture (uninterrupted) followed by a relatively extensive Q&A exchange. 2. A written version of the lecture-part of this session, together with the visuals used in it, will be available, upon request, from Dr Berglund, <anita.berglund@ki.se>. 3. As an extension of this session's Q&A, written Qs can be submitted to Dr Berglund over the next two weeks. She will collate and format them to anonymous Qs. Once she gets the As, she'll supply the added Q&A set, together with a written record of the Q&A exchange in this session, to all who submitted a Q and also to others who ask for it.

2 1. This lecture's premises and missions The main premises of this lecture are these two: 1. Here at the KI, the general imperative of academic excellence presumably is felt with heightened intensity. For this is, after all, the KI. 2. In the epidemiologic segment of the medical faculty here, the felt burden of this imperative presumably is heightened further by awareness of the confusion that now plagues epidemiologic academia everywhere; and in this segment of the faculty here, there therefore presumably is felt a burning need to resolve this confusion locally for a start, and then, under KI's leadership, globally. My main missions in this lecture, therefore, are these two: 1. To present my conception of what excellence of epidemiologic academia consists in. 2. To advance my vision of the epidemiologic segment of the KI medical faculty as the prospective pioneer and leader of an exceptionally excellent program, global in scope, of medical research.

3 2. The prevailing confusion in epidemiologic academia, fundamentally The depth of the prevailing confusion in epidemiologic academia comes to view, most notably, in the prevailing conceptions of the essence of epidemiology in it: Some academic 'epidemiologists' now define epidemiology as a study or a science, while others among them define it as a method. Besides, equally ill-defined 'clinical epidemiology' has arisen in clinical academia and has become an element even in epidemiologic academia, confounding it further as to the essence of epidemiology. In epidemiologic academia there thus is, at present, no shared conception of the essence of epidemiology, much less a shared-and-tenable conception of this. Epidemiologic academia thus lacks, at present, the requisite foundation for the development of truly productive programs of education and research.

4 3. Tenable conception of epidemiology: proposition In a tenable conception of it, I firmly hold, epidemiology is a species branch of medicine. Specifically, I define epidemiology as population medicine, a.k.a. community medicine and social medicine, serving its client populations re morbidity in them. The intended meanings of the 'notes' in this: 1. Medicine has professional healthcare (to humans) as its 'proximate genus.' And its 'specific difference' within this genus is the centrality of first-hand esoteric knowing gnosis about relevant-but-hidden truths concerning the client's health dia-, etio-, and/or prognosis, that is. 2. Populations (human) are of two generic, logically-defined types: closed (cohort-type) and open (dynamic). Client populations of epidemiology are all open. 3. Morbidity is the population-medicine counterpart of illness in clinical medicine. It is the frequency of the occurrence of an illness in the cared-for population. It is quantified in terms of rates of it rates of incidence of events of illness, prevalence of states of illness. Like that definition of epidemiology, these related concepts in that definition also are far from ingrained in today's epidemiologic academia.

5 4. Direct implications (analytic) of that definition of epidemiology My definition of epidemiology, above, has direct implications (per 'analytic judgements') which also are not part of the conceptual framework of today's epidemiologic academia: 1. Epidemiology is, inherently, population-level preventive medicine (supplementing individual-level clinical preventive medicine). 2. Epidemiology is, inherently, a segment of the professional realm of public health of societally-provided healthcare (medical & paramedical). 3. Epidemiology is accompanied by clinical medicine therapeutic and rehabilitative, as well as preventive in the medical segment of public health wherever clinical medicine has been brought into the public domain (per national health insurance). 4. Epidemiologists are community doctors (practicing community medicine). 5. Epidemiologic academics are not epidemiologists (as they don't practice community medicine); nor is epidemiological research epidemiology (but science).

6 5. Research implications (synthetic) of that definition of epidemiology Epidemiological research is research for the advancement of epidemiology. Research-based advancements of epidemiology involve a fundamental duality, corresponding to a fundamental duality in the research: 1. Availability of novel products and processes for it as a result of development based on (knowledge from) 'basic,' biological-type epidemiological research. 2. Improved knowledge-base of it based on (evidence from) 'gnostic,' statistical-type epidemiological research. Relevant research in epidemiologic academia addresses its teaching of the knowledge-base of epidemiology, and it thus focuses on # 2. (The biological research is conducted elsewhere in academia, and in industry too.) Regrettably, this sense of relevance does not animate the research in today s epidemiologic academia, even when etiology /etiognosis is addressed.

7 6. The methodology of the research in epidemiologic academia The methodology of etiognostic studies is now commonly taken to logically involve two main design options: the case-control study and the cohort study ; but this is a fallacy, a paralogism. Logically, the structure of etiogenetic studies actually is a singular one, that of the casereferent study. This term is, now, commonly presumed to be a synonym for case-control study. The case-referent study is founded on a defined study base, constituting the referent of the study result. The result is derived from the complete case series from the study base together with a suitable base/referent series from it upon these two series having been derived by needed reduction of the initial series from the study's source base (source population-time), in which the study base is inseparably imbedded.

8 7. Epidemiological research vis-a-vis clinical research: propositions 1. The fundamental duality in epidemiological research obtains, mutatis mutandis, in clinical research as well. 2. In statistical-type medical research there is, however, a fundamental difference between the two: While the epidemiological research is about rates, the clinical research is about probabilities gnostic, mainly diagnostic and prognostic but also etiognostic. 3. Gnostic probabilities for clinical medicine need to be studied through rates. In this sense, statistical-type clinical research is meta-epidemiological in nature. Its theory thus is an extension of the theory of statistical-type epidemiological research. 4. The requisite theory of gnostic clinical research meta-epidemiological as it is has not been understood in clinical academia, in the so-called clinical epidemiology there; but tenable theory of this research will be presented in an upcoming book, Clinical Research Transformed, developed as an extension of critical theory of research for the knowledgebase of community medicine.

9 8. Excellence of education in epidemiology: propositions 1. With epidemiology construed as one of the two branches of medicine, excellence of education in epidemiology is inherent in excellence of medical education in general (whether for epidemiology or clinical medicine). 2. Excellent education in medicine is founded on two (post-flexnerian) predicates: first, that education in whichever science is not education in medicine; and second, that substantive education covering all of the disciplines of modern medicine is as impossible as it is uncalled for. 3. Excellent education (and training) in modern medicine for competence in whichever one of its constituent disciplines begins with studies on the medical common: educational content that truly is relevant in preparation for whichever genuine rationally-defined discipline of medicine, such as communicable-disease epidemiology. The medical common is about the general theory of medicine. 4. Genuinely excellent education in communicable-disease epidemiology would be paradigmatic about excellent education in whichever well-construed discipline of medicine.

10 9. Excellence of education in 'epidemiological' research: propositions 1. In excellent education for 'epidemiological' research, preparation for metaepidemiological clinical research is included. (Hence those quotation marks.) 2. Excellent education for this research is suitably hierarchical: Thus, the focus is on original research before its extension to derivative research. And as for study design, very importantly, the studies' objects design is addressed prior to addressing their methods design. 3. Excellent education for the research begins with suitable propedeutics. The first module of these is a scholarly introduction to medicine and medical research. The second module covers tenable theory of epidemiology relevant to 'epidemiological' research. And the third one covers topics of statistics relevant to this research. These principles (i.a.) are heeded in the upcoming book Clinical Research Transformed.

11 10. Excellence of 'epidemiological' research proper: propositions 1. The knowledge-base of medicine gnostic is a global resource, in principle very precious; but at present it still is severely wanting as the basis for the practice of genuinely scientific medicine (whether clinical or epidemiological). 2. Preparatory to the development of this global resource of knowledge is the development of a global repository of needed evidence relevant (gnostically) in its objects and valid in its contents. 3. Excellence of research contributing to that resource is an attribute of the epidemiologic segment of a medical faculty, of its research program. Excellence of the program consists in its making contributions to the global resource of relevant-and-valid evidence (gnostic) at a high rate (given the size of the unit). 4. Excellence of the global repository of the evidence requires excellence of leadership in its development and functioning (notably its relevance- and validity-assurance).

12 11. Toward global excellence of 'epidemiological' research: a vision 1. A coterie of epidemiologic academics at the KI reflect on the contents of this lecture and study the manuscript of the book Clinical Research Transformed. This results in radical revision of education in epidemiology and, especially, in meta-epidemiological clinical research at the KI. 2. The epidemiologic academics at the KI, in collaboration with their clinical colleagues, develop an excellent design of a global program of developing the evidentiary base for the knowledge-base of scientific medicine. 3. The KI secures the collaboration of medical faculties throughout Sweden and, ultimately, on a global basis, and also helps secure the funding for the program to be led by the epidemiologic academics at the KI. 4. The program begins.

13 12. Closing note In that vision, I see the epidemiologic segment of the medical faculty of this august Institute heeding in its planning ('strategic') for its future excellence the advise Daniel Burnham gave on urban planning (to the Chicago City Council at the turn of the 20th century): Make no little plans; they have no magic to stir men's blood,... Make big plans; aim high in hope and work,... This I really expect of the epidemiologic academics here at the KI. For, in the face of what I regard as an unassailable vision of global excellence of directly practice-relevant medical research under their leadership, the alternative to taking on the mission would be philistine indifference to the quest for a scientific knowledge-base for medicine and this I just don't see to be in the culture of the faculty that awards Nobel Prizes in Physiology or Medicine.