Evidence and Education

Abstract

Given the illustrious list of prior awardees, I feel deeply honored to have been the James B. Herrick Lecturer for 2010.1 In planning my Herrick lecture, I thought it would be instructive to use the legacy of Dr Herrick as a lens to assess the evolution of how we acquire evidence and organize our educational mission. This article is based on the 2010 Herrick Lecture but also includes some additional material derived from my own experience in clinical research and writing guidelines documents. Ninety-eight years ago, Dr Herrick published his classic article on the sudden obstruction of a coronary artery, emphasizing that this event was not uniformly fatal.2 He hypothesized that when a coronary was occluded, left ventricular function could be preserved by enhancing collateral flow.2 Herrick was clearly a master clinician, a keen observer of his patients, and, I would argue, a nascent clinical investigator. However, unlike today's clinical investigators, Herrick was not able to test hypotheses, such as the one about improving collateral flow, because conspicuously absent from his black bag were modern day methods for acquiring the evidence to make an informed therapeutic decision. Our evidence toolbox grew with a watershed event in 1948 when Doll, D'Arcy Hart, and Avery Jones working in the United Kingdom introduced the concept of randomization of individual subjects.3 These early randomized controlled trials (RCTs) were not in cardiology but involved pertussis vaccine and streptomycin for tuberculosis. Major research concepts that influence our contemporary research strategies including informed consent, the ethics of RCTs, and blinding grew out of this early experience. Another major advance in clinical trial methodology came 10 years later in 1958. A mathematician working at Bell Labs …