|
3
Nerd-Its
|
|
article
by There is rampant and conflicting advice concerning the use of epidural analgesia during labor. A collection of recent and pertinent research on the topic identifies a handful of confirmed risks and benefits, and exposes numerous other items as nothing more than rumor.
Add a Comment (34)
Email This
Message Author
I have found as a labor and delivery nurse that the results of the studies are not necessarily accurate.
In any delivery, with or without an epidural, there are interventions that nurses/medical personnel impliment to prevent/correct malpositions, the need for the use of pitocin, the need for an episiotomy, etc.
I would be very interested to know how the studies were performed and what other interventions were performed by the professionals caring for the patients and if the same interventions were used on all patients.
What I have seen as a labor and delivery nurse is the use of epidurals in most (80-95%) cases actually reduces the length of labor, increases patient satisfaction of pain relief, decreases the need for episiotomy, decreases the incidence of perineal tearing, is less harmful to the fetus, decreases maternal anxiety regarding delivery, decreases maternal fatigue and thus increases maternal satisfaction with the whole birthing process and gives the patient more control to assist with the delivery.
There also appear to be several things the studies do not take into account. One of which is that physicians and hospital policies to reduce liability and increase good outcomes of labor and delivery, require patients to have either intermittent or continuous fetal monitoring which in itself reduces the mobility of the maternal patient as the patient is connected to a monitor by cables. The use of the epidural does not change this. Yes, there are some hospitals that do not require this, however, they are not in the majority.
If we consider the physiology of labor and delivery, it must be noted that a woman in pain from labor is not relaxed during contractions. This in itself lengthens the time of labor for first time moms in most cases as well as in multipara patients. During a contraction, patients tense muscles due to the intense pain; this slows the decent and increases the length of labor. With the use of epidurals, the patient does not experience intense pain during a contraction and therefore does not tense muscles, allowing the labor to progress at a more rapid rate. This is shown to be true by patients being in labor for numerous hours without the epidural and making little or very slow progress and then when they get the epidural placed, are able to relax and progress quickly. It is very common to sit a patient up for epidural placement with a cervix that is dilated to 4-6 centimeters and after epidural placement and the relaxation of the muscles to find the patient has progressed very rapidly to 8 cm or more within a very short period of time. I cannot say this happens in every case, but it happens more often than not. Also, since the patient is able to relax after an epidural and actually rest until delivery, the patient has more reserve energy to assist with pushing. Also due to the decrease in patient fatigue, the patient is more likely to have a better bonding experience after delivery and have the energy to actually work on breastfeeding the newborn.
The medication given to patients intravenously crosses the placenta and affects the fetus. This is evidenced by the fetal heart rate tracing which shows decreased variabilty after IV medication. Intravenous medications do not control pain after one dose, but must be repeated to keep the mother comfortable. In cases where the fetal tracing is not reassuring, whether due to the medication administered or other reasons, the patient does not have the option of repeated doses of pain medication to maintain pain control. The medication given during an epidural does not cross the placenta to the fetus. Fetal distress after an epidural is not due to the medication reaching the fetus, but due to drops in the maternal blood pressure which is easily corrected by giving boluses of IV fluids and in extreme cases, Narcan, a medication that reverses the effects of the medication. This drop of blood pressure is easily prevented by assuring the patient is properly hydrated prior to the placement of the epdiural. In most hospitals, the epidural once started is continuous drip which keeps the patient comfortable until after delivery at which time the drip is discontinued.
Due to the fact that the patient is not out of control due to pain and/or the urge to push, the incidence of episiotomy/perineal tearing is reduced as the pushing process is more controlled with an epidural. This increased control gives the patient/nurse more time to stretch the perineum which decreases the incidence of episiotomy/perineal tearing. A patient that is in intense pain from the delivery process cannot always control the urge to push.
As with everything is life, there are downsides otherwise known in the medical profession as "risks and hazards" in labor and delivery. Some of the risks and hazards of epidurals as listed in the studies may have been the direct result of the individual physician practices. There are many physicians who do not allow patients to progress naturally through labor and delivery without the use of interventions to speed the progress of labor and/or delivery, including the use of pitocin, forceps, vacuum extraction and/or Cesarean sections. This is often a result of the physician preference to "get a good night's sleep" (i.e. not be called for delivery in the middle of the night), a busy office practice, need to be in meetings, desire to be with their own family for events/family time or numerous other life distractions. This varies of course from physician to physician; just ask any labor and delivery nurse to find out which physicians are more likely to rush to a Cesarean section, use forceps or vacuum extraction, use pitocin, use artificial rupture of membranes to speed labor, etc. In defense of the physicians, most patients to not want to spend 12-48 hours in labor/pain. The physicians are also under pressure from the patients and hospitals to speed up the labor process to "facilitate effective use of labor and delivery personnel". There is a nursing shortage after all. Nurses are not allowed the luxury of sitting at a patient's bedside (one on one) during labor and delivery. Although in high risk cases, a patient may have a nurse full time, the "normal" laboring patient has to share her nurse with 1-3 other patients, depending on hospital policy and/or the shortage of labor and delivery personnel.
As with any science, it is possible to sway "studies" to reveal the results the scientist is looking for, whether or not it is intentional. Other factors that can alter the outcome of studies is the attitudes and expectations of the patients in the actually study. Do they want an epidural, does someone try to talk them out of the epidural pain relief (yes, this happens often), are they afraid of needles, have they heard "horror" stories from "friends or family" about being paralyzed for life or other side effects of epidurals, have they been educated on the process of epidural placement and what to expect from epidural analgesia. Many factors affect the outcome of studies.
What I have seen during my experience as a labor and delivery nurse is that epidurals usually shorten the length of labor and increase maternal satisfaction with the labor and delivery process.
Basically, whether or not to have an epidural during labor/delivery, should be decided by the patient that has been educated regarding the process of epidural placement and not the outsome of a study. Unfortunately, not all patients are given the education of what to expect from an epidural and the placement procedure. Again, unfortunately, not all anesthesiologists place epidurals in the same manner, use the same medications in the epidural and do not all have the same skills in placing epidurals. Many anesthesiologists aim for the "total pain relief" epidural while others aim for "taking the edge off the pain and allowing for more control during the labor/delivery process".
There have also been labels given to maternal patients if they choose to have an epidural. In some cultures, women are urged to endure the pain which supposedly makes them more of a woman for having natural childbirth. Trust me, delivering the head of an newborn (roughly the size of a large grapefruit) through an opening the size of a plum incurs pain and the patient does not get any extra credit for doing it with intense pain.
Studies have there place. I just feel that each patient needs to take into consideration what can actually affect the outcome of the study. Each patient also needs to take into account what they hope to get out of the labor/delivery experience. I feel that there are a lot of unsubstantiated misconceptions regarding the placement of epidurals due to all these studies that have had such varied results. I have also noted that a lot of these studies are conducted by the male of the species and trust me, they do not have the same perspective as a female on the labor and delivery process.
From a real life perspective, I have not seen epidurals slow labor, increase the incidence of Cesarean section/mechanically assisted delivery or unfavorable effects on the fetus. If anything, I see increased satisfaction with the process, decreased fatigue and better control by laboring patients (which decreases incidence of mechanically assisted deliveries) and a shorter course of labor.
Just thought you might like to have an opinion from someone who does this for a living. Unfortunately for Brandon, that also happens to be his mother-in-law!
It's good to hear the experiences of someone in the industry. I think many of your thoughts are dead-on. I have questions/comments on some things, though.
I'm interested in your comments on the effect epidural analgesia has on the length of the second stage of labor. Why do you think your experience is in such contrast to what is consistently found in the cited studies?
Your point about the individual practice of doctors is a good one, but wouldn't a randomized trial include both doctors who are quick and slow to intervene? Or, do you think the overwhelming majority of doctors are in one of the camps? In any case, it would be interesting to see a study on the "patience" of the doctor (or maybe even where work fits on their priority scale?) and how it affects the rate of intervention ... or even long-term mother/baby health.
I'm not sure what you mean about basing your decision whether or not to use an epidural on learning the epidural procedure, rather than study results. Even if I completely understand what is going to happen (as much as a layman can, that is), I could have significant holes in my understanding its risks or potential consequences.
In regard to your questions/comments, I "consulted" some of the other nursee I work with and this is what we came up with.
1. We all wonder again how these studies were conducted. Were they only including primiparas (first time moms) in their studies? This would account for some discrepancy as primips have not had the experience of "pushing to delivery". Even in patients without epidurals, this is a learning process. In the case of a primipara that is out of control with pain, the process can take hours. Also, we questioned the interventions performed by the patient nurses to facilitate the second stage of delivery. We also question, again, the type of epidural placed; were the epidurals studied all performed in the same manner, at the same time in the labor process, the same density of epidural and with the same medication? This can make a huge difference in the time it takes to deliver after an epidural. Again, I have not conducted a "study" of the above, but may start taking notes on what effects my own patients.
2. As to the individual practice of doctors, a randomized trial should have included both doctors who are quick to intervene and those who are not. Unfortunately, I would have to say that the majority of doctors fall into the category of "quick to intervene". Physicians are just humans after all and although may have become physicians for the right reasons, have over time become conditioned to "take the easy way out" for a number of reasons. One of these is the increased cost of malpractice insurance. A physician is more likely to get sued for not having done enough or in a timely manner than he is for having patience and waiting to see if the patient can deliver without mechnical interventions. After all, would you rather have a child with brain damage due to insufficient oxygen during the labor/delivery process or a healthy baby that had mechnically assisted delivery? Obstetricians have one of the highest malpractice rates overall - parents do not want their infants harmed and the high cost of caring for a handicapped child is life long for that couple.
3. As for basing the decision whether or not to have an epidural based on knowing the procedure that is actually performed, it would help disspell the rampant rumors and old wives tales about the pain incurred during an epidural and the effects the epidural will have on the recipient. I cannot tell you how many times I have had patients state to me that there is no way they will have an epidural because they do not want to become "paralyzed for the rest of their lives". I realize these may not be the higher level of intelligent patients as the person that has told them they will be paralyzed for life is in fact walking around in the delivery room at the time the patient makes the statement, but knowledge of what to expect during and following the procedure, allows the patient to make an "informed consent". When the epidural process is taught to patients prior to placement in our hospital, the risks and hazards of the procedure are discussed with the anesthesiologist and the patient/spouse have the opportunity to ask questions and it is very important that the patient/spouse ask any questions they have prior to the procedure. The anesthesiologist also explains to the patient exactly what he/she is doing as the procedure progresses and what to expect as well as what to report to indicate that placement of the epidural is not optimal.
In any procedure that is performed, there are risks and hazards associated and it is the law that patients be advised of these before signing a consent form so the procedure can proceed. This teaching process should start during OB visits and unfortunately, many times does not. Unfortunately also, even though the patient is informed of these risks and hazards at the time the epidural is placed, the majority of patients are in such intense pain, their only thought is to make the pain disappear.
The studies stated that patients that had epidurals had a higher incidence of back pain/problems after having epidurals. This may, in part, also be due to having been told by "friends and family" that they had back pain after an epidural. Any women that is pregnant and delivers an infant is at risk for back pain, whether or not they had an epidural. The actual delivery of an infant changes the anatomy of the female pelvis and thus can affect the anatomy of the spine and/or the nerves that intervate with the spine. This change in anatomy is most often the cause of the post delivery back pain.
As far the long term effects of epidurals on an infant, the infant does not receive the medications given in an epidural. This in itself should be a "pro" to getting an epidural. Intravenous medications to cross the placenta to the infant and can cause decrease fetal heart tone variability which indicates that the infant may be in distress. Infant reserves are much smaller than an adults and are affected by the side effects of the medications that cross the placenta rather than those that do not cross the placenta.
I see patients with an epidural much more in control of there progress than those that are out of control with pain.
Hope this answers some of your questions. If not, let me know and I will try again.
Kay
Thanks, again, for the comments from industry.
- I agree the points you brought up (e.g., whether or not it is the mother's first child and administration differences) are important variables that would need to be controlled in a properly designed experiment.
- Sad, but insightful.
- My comment wasn't meant to question if pre-decision/operation information is a good idea. It obviously is. I meant to point out there are things research (such as that provided here) can add to the decision-making process that a strictly functional understanding of the procedure cannot.
The studies stated that patients that had epidurals had a higher incidence of back pain/problems after having epidurals.
Actually, they stated the opposite. The applicable studies (in 2001, 2002 and 2005) found no association between epidural analgesia and long-term backache.
As far the long term effects of epidurals on an infant...
I didn't see any agreed-upon long-term effects. Studies in 1998, 2002 and 2005 looked at things ranging from Apgar scores to neonatal behavioral issues to funic acid-base status, but there wasn't a clear consensus on any detrimental effect.
You do realize my article concludes positively about the procedure, right?
I signed in this time for you.
You've had me going on and on about my critique of your article, and you have protested about having to summarize the cited studies' experimental designs, and yet now it is unclear if you read the articles yourself!
Something you said in your last comment to me tipped me off. You said that those seeking further context could go on to the next step that being to read the cited article abstracts. Well thought got me thinking, are your references to entire papers or are they to just abstracts. And low and behold, the majority of your "study" references only contain abstracts. Since I work at a university I can access the full text of the articles but others would have to pay for access. So I have to ask, did you only read abstracts on these studies?
I think it is important to convey to others that an abstract gives one a very limited view of an article, usually just the results and limited conclusions. You don't cite an article if you only read the abstract.
So I am very interested in knowing if you read all of these articles or not.
I didn't read the ones you have to pay to access. Unfortunate, yes, but it doesn't detract from the purpose of my article as stated.
Now, as you have access to the full versions, maybe you'll enlighten us with insights gleaned from them ... or maybe you'll go off on "how dare I" provide summarized information from articles I haven't read in full. I guess it depends on why you're here and commenting.
Now, as you have access to the full versions, maybe you'll enlighten us with insights gleaned from them ... or maybe you'll go off on "how dare I" provide summarized information from articles I haven't read in full. I guess it depends on why you're here and commenting.
To be honest I'm not really interested in pros/cons of said procedure, but since you emailed me with your article, I assumed as I always do, that you were looking for critique/feedback. Usually with your articles, I will read them and that's it. Sure sometimes I see a flaw in design but most of the time they are really minor or are stylistic critiques. This article is something totally different altogether. You are providing information on which others will make medical (potentially life altering) decisions. Granted, an Omninerd article isn't going to be way up there in peoples Google searches, but they may come across it and your article is fatally flawed. You have a very limited scope of understanding about the papers you cited. And don't get me started on the ethics of citing a research paper when you only really read an abstract, they are to be cited as two separate things in case you didn't know.
It shouldn't be my responsibility to fix your article, if this were a news post maybe I wouldn't care, but as an article this is really sloppy Brandon, and I am curious as how you reconcile your actions. If it were mine I would have included the changes I spoke of or I would retract said article. Do you honestly think that because something appeared in PubMed that it applies to your article? Do you not understand the difference between exploratory research and controlled experiments?
You write as if I am just taking my time to moan about this because I have nothing better to do. Believe me, I have better things to do then engage in something petty, but this is a really serious error here. Whether you believe it or not you are giving people information on which to make medical decisions and you haven't even read the information that you are passing on. Doesn't that seem a little irresponsible to you?
I assumed as I always do, that you were looking for critique/feedback.
I was, and I'm always glad when people take me up on it.
You are providing information on which others will make medical (potentially life altering) decisions.
Well, I'm passing information along as being something I found applicable to the topic. I hope it helps people make a more informed decision - or even just satisfies some curiosity. I know it would have helped me with both a couple of months ago when I was studying the subject.
[abstracts and full papers] are to be cited as two separate things
I didn't know that. What do you do differently? (Go on, flex your nerdiness.)
It shouldn't be my responsibility to fix your article
It's not. And, if anything needs to be fixed, it's the system that requires money to read the research.
The reason I ask you to share is twofold:
- I'd like the discussion on my article to contain as much helpful information as possible.
- I'm curious if you'd find anything there that would show my article to be the danger I think you're accusing it of being.
I am curious as how you reconcile your actions.
I explained it a few times now.
Do you honestly think that because something appeared in PubMed that it applies to your article?
No, just the recent research about the pros/cons of epidural analgesia during labor/delivery.
Do you not understand the difference between exploratory research and controlled experiments?
I think I do. Exploratory research vs Controlled experiments.
you haven't even read the information that you are passing on.
Assuming the reader has the same access I do, I've read the majority of it.
Doesn't that seem a little irresponsible to you?
Irresponsible in what sense? Because my brief comments could totally misrepresent the publication summarized? I guess that's possible, but extremely unlikely. As you've noted, I kept things very simple, leaving the reader two choices: accept the obviously limited summary for what it is, or go to the original source for more information. It'd be different if my article pretended to me more.
I'm passing information along as being something I found applicable to the topic
But if the research is only exploratory is it applicable to the general public? You own wiki definition states, "Exploratory research is not typically generalizable to the population at large".
if anything needs to be fixed, it's the system that requires money to read the research.
maybe so, but that doesn't excuse one from using incomplete information, i.e. an abstract, and pass it off as a well researched citation.
No, just the recent research about the pros/cons of epidural analgesia during labor/delivery. (is applicable)
If a study is exploratory it should be cited as such and the findings can't be universally implied. Your Bodner-Adler paper stated this in it's own conclusions; "A possible explanation for this finding could also be that women with abnormality in labor may have more pain and therefore preferentially end up in the epidural group." This is an acknowledgment of the studies limitation since they also state in the methods that they merely reviewed a hospitals records to evaluate their data. I think that squarely places them in the realms of exploratory studies.
Your Howell paper that is entitled "A randomised controlled trial of epidural compared with non-epidural analgesia in labour" sounds like a control study. However if you read further in the paper you find that "The hypothesis being tested was that of intention to use epidural or non-epidural analgesia for labour. Hence there was no plan to undertake secondary analyses according to treatment received, as this would change the design of the study to that of an observational series." Basically if a women said she didn't want an epidural but then decided she did want one, she remained in the non-epidural group. This may seem counterintuitive but the research goal was to access satisfaction and this was still maintained. Some of the results that followed though would have been strengthened by a secondary analysis. Basically, those other results were viewed as icing on a cake and they didn't bother to reexamine for validity since they were already outside the scope of the study. Yet you don't present them as such do you?
Irresponsible in what sense? Because my brief comments could totally misrepresent the publication summarized? I guess that's possible, but extremely unlikely
Is it unlikely? I just took two publications and have shown how the results presented are in the first paper were not meant to be used to make a generalized statement of fact or causality since they appear to be exploratory, and in the case of the second paper the reported results were outside the "controlled" study and therefore also must be viewed as exploratory.
As you've noted, I kept things very simple, leaving the reader two choices: accept the obviously limited summary for what it is, or go to the original source for more information. It'd be different if my article pretended to me more.
But you didn't provide a summary you provided a table of facts linked to sources for which you assumed have real relevance to your topic. You entitled your article "pros and cons" signifying that these results either speak for it or against it, yet the majority speak only of corellations that must be further established. This is how you closed your article:
The undisputed risks seem to be a longer labor, greater cost and higher chance of instrumented vaginal delivery, while the undisputed benefit found is effective pain relief.
That is irresponsible since these "risks" aren't established in your studies. The one controlled study established that there was no difference in back pain in it's experimental design, but they didn't have the balls to make the statements above. That is a misrepresentation.
Oh and FYI if you use an abstract and not the entire article you are to cite only the abstract. You would do this by signifying abstract in the title. You should also know that to cite an abstract, at least in the scientific community, is in extremely poor taste. It is only done if the paper hasn't been published but the abstract/results were presented at some academic forum. I really can't stress that enough, an abstract isn't equal to a publication and if a publication exists, the publication should be evaluated and then cited. If you cite a publication then it is to be assumed that the publication in it's entirety was accessed.
if the research is only exploratory is it applicable to the general public?
I'm not familiar with the nuances of this, but as I wrote the article, all of the included studies seemed to fit the requirements I listed earlier.
pass it off as a well researched citation
That's my point: I didn't pass it off as anything. It is what it is, I just helped the reader find it.
[discussion of study details] Yet you don't present them as such do you?
No, my goal wasn't to present the details, only to point the reader to the studies to find the details on their own. Although you identified a couple of things that are interesting and important to a full understanding (and could probably find much more), the article's stated purpose remains intact.
I wish you'd spend more time talking about the interesting points from the research rather than trying to convince me my article should be something I never intended it to be.
you provided a table of facts linked to sources for which you assumed have real relevance to your topic.
The facts I presented are that certain studies exist, they contain certain information and can be found in certain places. This is much different from stating a particular claim is a fact. Notice my wording is "the study concluded X" or "the review identified Y," not "X is true" or "Y is factual."
[cites article conclusion] these "risks" aren't established in your studies
My conclusion says they were undisputed (not established) - meaning there weren't studies that disagreed in the group I included.
You should also know that to cite an abstract, at least in the scientific community, is in extremely poor taste.
Thanks for the details on how to cite the abstract. I'm sure it's in poor taste in the scientific community, but as long as I'm writing for OmniNerd and not a peer-reviewed academic publication, my standards probably won't be the same. Granted, I will still strive to provide quality information - and I'd argue OmniNerd does that better than the vast majority of cyberspace - but there are many instances in which my goals don't necessitate meeting all of the requirements for journal publication.
I'm not familiar with the nuances of this, but as I wrote the article, all of the included studies seemed to fit the requirements I listed earlier.
I don't think you understand the difference at all man, because you continue to say that your sources show aren't exploratory studies. Your requirements for this article must have been that it was a peer-reviewed article that discussed something about epidurals, period.
It is what it is, I just helped the reader find it.
And I just stated it would have been nice if you gave the reader some context of the article so they could better evaluate the source, which would have helped you to better evaluate the source before using it.
No, my goal wasn't to present the details, only to point the reader to the studies to find the details on their own
You are wrong here man. If your goal wasn't to present details you would have just provided a list of studies and not their findings. You choose to take results and present them as factual information. The authors of your papers don't present any of the results in the manner you did. Nowhere in the papers do they say that Epidurals = X because the ones I skimmed are mostly exploratory and the limitations of the study dictate they can't make any such statements. If you had bothered to read the discussion of the papers you would see that they don't conclude these things either. They state their results suggest X but then list the limitation. I feel like a broken record here and you just don't get it.
My conclusion says they were undisputed (not established) - meaning there weren't studies that disagreed in the group I included.
So because you didn't cite it or find a study these results are undisputed... that's very presumptuous of you Brandon. I would call that irresponsible and if they ever put such on the news I would be shocked. (Doesn't mean it doesn't happen but most journalists shy away from such remarks.)
but as long as I'm writing for OmniNerd and not a peer-reviewed academic publication, my standards probably won't be the same.
Fair enough, but you should know that in college you can't cite an abstract and in high school you can't cite an abstract either (that comes from my own experience and a father who is a high school chemistry teacher.) It's like citing an encyclopedia, it's just not in good taste. And if Omninerd doesn't value the minimum standards of a high school how does that reflect on Omninerd?
Your requirements for this article must have been that it was a peer-reviewed article that discussed something about epidurals
Close. My requirement was recent peer-reviewed studies about epidural analgesia as used in labor/childbirth.
it would have been nice if you ...
Saying something "would be nice" is much different from the serious moral accusations you seem to be making elsewhere. I agree there are probably lots of things I could have done to tweak it; it's the claims of "irresponsibility" with which I disagree.
(By the way, if you're interested in helping me revise my articles before I publish them, tell me and I'll send you a note when I'm ready for a review. OmniNerd is nicely setup for article collaboration.)
You choose to take results and present them as factual information.
I've already shown this not to be the case.
Nowhere in the papers do they say that Epidurals = X
And neither do I.
I feel like a broken record here and you just don't get it.
Ditto.
So because you didn't cite it or find a study these results are undisputed
Not generally undisputed, but undisputed in the studies I included. That's how I stated it in the conclusion ("[T]he studies/reviews analyzed indicate...") and it's quite accurate.
if Omninerd doesn't value the minimum standards of a high school how does that reflect on Omninerd?
OmniNerd's content speaks for itself. Feel free to look around the web and make comparisons.
Brad, I just wanted to say that I agree with you on every point of contention that you listed in regards to this article. As a physician, I would never make any treatment recommendations based on reading only the abstract. From my experience, the abstract can be very misleading as to the exact nature of the how the study was performed, in addition to the actual validity of the results. Very frequently I will come across a study abstract which seems to test one variable or another, and seems to make a conclusion after said testing, only to find upon reading the actual article that the study design itself is either inherently flawed, or that the results are pulled from circumstantial data from variables not initially intended to be tested in the study design. This is the danger of only reading abstracts - you have no idea what the study process entailed or even if the results are able to be trusted.
To improve clinical practice, physicians read multiple articles (not just abstracts) and shape their practice accordingly. I use evidence from well designed studies to present patients with their options, various pros and cons of each, and let them make informed decisions regarding their treatment plan. This article is written to accomplish the same end, as indicated by the title. However, as Brad has pointed out, it lacks the foundational basis for the "pros" and "cons" it claims to present. The article lists conclusions, ie pros and cons, without a thorough exploration of how those conclusions were drawn, if they are valid, or if they are even applicable.
A potential patient could read this article and make a decision based on results that could be completely flawed! Then that patient will walk into my office and I'll spend unnecessary time trying to re-educate them on the real evidence, real pros, real cons. In the end they'll likely stick with their ill-informed choice because who can trust doctors anyway? Better trust what you read on the internet...
Thank you!
For a while I felt like I had taken crazy pills or something. Granted Brandon and I go way back and I know how rarely he will cede a point on anything especially if it is just me debating it, but this mistake just really rubs me the wrong way. So thank you for putting your two cents in and making me feel like I wasn't alone on this.
My issue with your criticism (and Brad's) is it's not aligned with the purpose of the article - which is simply to gather recent and relevant studies on the subject and present them for further investigation to the interested reader in an organized fashion. Of course there are important details in the research papers themselves - that's why they exist and are longer than 2-3 sentences. Repeating this information, however, is not my business. Not being a professional in the industry, what could I add? My only contribution is to find the publications, organize them, and then present them here - hopefully saving others like me a lot of time.
The other concern you voice is the potential danger in misleading a reader - but this again seems to ignore the probably audience. I see people as falling into one of a few groups when dealing with topics such as this (i.e., those on which the layman is typically ignorant):
- Joe Schmoe - Joe isn't interested in research - or in reading, for that matter. He wouldn't likely find my article, and if he did, he most definitely wouldn't read it. ("Epi-what? Where's my beer...")
- Bob Schmoe - Bob isn't interested in being knowledgeable, only in appearing that way to others. It is also unlikely he will find the article, but if he does, he may scan the introduction or summary/conclusions to try and pick up bits of information he can spout off later. He won't read the included details of the cited references (or care if they exist), much less the references themselves.
- Tom Schmoe - Tom sincerely wants to understand, but he lacks judgment. He will search online and read one or two of the top results - accepting their claims without discrimination as to the quality of the article. He may come across my article, but it's only the summary/conclusion which would stick. He can't discern between a properly formatted abstract or experimental design just like he can't sift through online info to find a quality article.
- Bill Schmoe - Bill also sincerely wants to understand, but he's smart. He searches online and is able to pick out the quality sources. He might come across the article, and he'd see it for what it is: a time-saver. Now he can pick out the studies in which he's most interested and investigate to his heart's content.
- Ted Schmoe - Ted is a researcher or perhaps works in industry. He doesn't search around much because he already knows the answers - or at least knows exactly where to look and who to ask. He wouldn't read an article like this unless he had a separate reason to - in which case he'd be able to offer additional information or interpretation.
Which of these groups stands to be in danger due to my article and its stated scope (not danger they would be in anyway, of course, but an actual created danger)? Joe and Bob are hopeless, as any additional clarifications would have gone unread. Tom isn't much better. It would take a day-long seminar to instill the discernment he needs to appreciate the details you seek. And, when he did gain this judgment (and his name became Bill), he would be astute enough to realize he should go to the source for the details, given the scope of this article. Lastly, there's Ted, who obviously isn't in any danger of being misled.
My issue with your criticism (and Brad's) is it's not aligned with the purpose of the article - which is simply to gather recent and relevant studies on the subject and present them for further investigation to the interested reader in an organized fashion.
But you didn't just gather some sources that may be of use, instead you listed results of said sources and used those results as the basis for your "organization". Those results may not be entirely accurate in the form you present them, as shown in some of my examples, nor do they apply to the general public which is the likely interpretation of your paper. It doesn't matter if that wasn't your interpretation so far all of the comments on here have felt that this was the case. My criticism was for you to add explanations of the studies so the results would have context and yes context is needed to interpret these results, they aren't black/white like you present them.
My only contribution is to find the publications, organize them, and then present them here - hopefully saving others like me a lot of time.
The you should have done so by either A) listing the the studies and the variables they were looking at (i.e. a title) B) or be done as we have been saying and provided more context. If your only goal was to give publications then you should have left results out of it, it would have been much more ethical (meaning you would diminish the chance that your article would mislead).
The other concern you voice is the potential danger in misleading a reader - but this again seems to ignore the probably audience.
You never know your audience unless it is restricted and for you to claim otherwise is just further evidence that you don't care how your work is perceived/used.
I'm curious Brandon which schmoe you would call yourself. I'm assuming Bill, yet what does that say about your "target audience" seeing as how you didn't even read the articles you cited and think that you understand them fully, or at least enough to discern the researchers results, and then pass that info on.
My point is Brandon, how exactly did you evaluate your references if you didn't read them fully and if you couldn't evaluate them, why would you pass them on to others? Why pass something on that you haven't read? You didn't go to the source, so are you Bob or Tom? Seeing as how you haven't ceded on inch on any of the critique maybe you are more Tom than Bob. By you definition of Bob I would say you are Bob and Bob shouldn't be writing articles like this.
Those results may not be entirely accurate in the form you present them
I think my organization is sufficiently vague so as to not mislead the reader, your examples notwithstanding.
My criticism was for you to add explanations of the studies so the results would have context
In understand your criticism, I just don't agree. I prefer the reader go to the source for details.
If your only goal was to give publications then you should have left results out of it, it would have been much more ethical (meaning you would diminish the chance that your article would mislead).
I think the info included adds value, and introduces a negligible risk of misleading (as I've explained already).
You never know your audience unless it is restricted
If you're going to play that game, then you should realize you can't even know it then. I guess we should pull all info off of the 'Net?
which schmoe you would call yourself
Yes, Bill is probably closest.
you didn't even read the articles you cited and think that you understand them fully
I don't think I understand them fully.
or at least enough to discern the researchers results, and then pass that info on
Yes, I understand them enough to categorize them in the manner I did.
how exactly did you evaluate your references
I explained this already: recent published research on the topic at hand.
why would you pass them on to others?
I explained this already, too. The collection/organization is helpful. I know it would have saved me a lot of time if I had found it during my search.
By you definition of Bob I would say you are Bob
You're categorizing someone who writes an article like this the same as someone who won't even read an article like this? Maybe you're just trying to get a rise out of me, but that's downright silly.
My interest in learning is obvious and speaks for itself.
You're categorizing someone who writes an article like this the same as someone who won't even read an article like this? Maybe you're just trying to get a rise out of me, but that's downright silly. My interest in learning is obvious and speaks for itself.
My categorizing you as a "Bob" was based on your own definition of that kinda of person. I quote: "Bob Schmoe - Bob isn't interested in being knowledgeable, only in appearing that way to others. It is also unlikely he will find the article, but if he does, he may scan the introduction or summary/conclusions to try and pick up bits of information he can spout off later. He won't read the included details of the cited references (or care if they exist), much less the references themselves."
Isn't that what you did, you found some references scanned the abstract and spouted of some results later? Did you read the include details of the cited references in your articles? Or care if they existed?
You claimed that you thought you understood the articles well enough to discern what info could/should be used in your article, yet I showed with just two of the papers that you didn't understand the scope of the studies and that the studies themselves shouldn't be applied to the general population. So how is that an appreciable understanding of the study?
While PubMed is a useful tool, it is easily misused. Take it from someone that reads articles all day long, it is an exhaustive exercise. You have to read the entire article and then you need to re-read the article. Next you have to go through the references and begin to back check come of those to verify the logic/experimental design of the article. Then one can begin to access the scope of the study and whether it applies to what you wish to use it for.
I get what you were trying to do, I do. I just found your "Schmoe Chart" ironic since you ascribed some of the same errors you made to someone that you would consider of lesser intelligence (maybe that's the wrong word, maybe it's a lesser desire for understanding).
In understand your criticism, I just don't agree.
in the end it doesn't really matter if you agree or not Brandon. My criticism was intended to polish your paper and give it some credibility of authorship. If you choose to not accept it, it will only result in others viewing your work as subpar or mediocre (and to some, those in the profession or others, irresponsible and misleading).
On a side note: your comment about maybe no info should be available on the web makes for an interesting discussion. While I agree that open access information is essential... what are the negative effects of people reading something, thinking they understand it, and then passing it on. I know having two brothers who are doctors that the number of patients that come in thinking they understand their condition/procedure because they read some web links is high. The percentage of those people that have mis-information is also extremely high. So, does all this "free" information help or hurt. Consider also that one could access these same medical journals before the internet as well. The rise is in articles like yours and sites that seek to diagnose and tabulate info and do so poorly.
Isn't that what you did, you found some references scanned the abstract and spouted of some results later?
No. Bob is looking only for info to fuel his claims. If I were Bob, I would have written you an email saying, "Epidurals are totally XXX. I read like a million studies online saying so." Instead, I spent a good deal of time bringing together information to share so others could study the topic for themselves.
I showed with just two of the papers that you didn't understand the scope of the studies and that the studies themselves shouldn't be applied to the general population. So how is that an appreciable understanding of the study?
I've already explained this, and I don't understand why you are repeating the protest. You know my requirements for inclusion (namely, being on-topic and recent), and you haven't identified any study as being outside of them.
You have to read the entire article and then you need to re-read the article. Next you have to go through the references and begin to back check come of those to verify the logic/experimental design of the article. Then one can begin to access the scope of the study and whether it applies to what you wish to use it for.
That depends on how you want to use it. If I were performing research or practicing medicine, the requirements are obviously different than if I were compiling a list of articles authored in 1966 by someone named George. In my case, the understanding was sufficient for the use.
My criticism was intended to polish your paper and give it some credibility of authorship. If you choose to not accept it, it will only result in others viewing your work as subpar or mediocre (and to some, those in the profession or others, irresponsible and misleading).
You're placing the article in the wrong peer group. If you'd accept it as being merely a useful organization of information sources for those interested in the topic, and not something in an academic journal, your tune would change.
As for the availability of information, I think the more the better. It should be left to the individual to decide to what extent he will go in understanding and applying information. From a generalized standpoint, I don't think the "institution" should screen out what the public "isn't ready to handle."
articles like yours and sites that seek to diagnose and tabulate info and do so poorly
My article doesn't attempt to diagnose at all, but the information is "tabulated" accurately.
[Show/Hide]
[Reply]
0 Nerd-Its
That sure cleared it up...not by Anonymous :: NR0 :: on 08 November 2007
While one can appreciate the effort the author exhibits in attempting to present these findings, the findings don't really mean anything if they aren't presented in the context of the scientific studies. I think such "summary" articles serve as a disservice to people since they rarely incorporate the conclusion/discussion sections of the articles but rather seek to just present results. Results need to be reported in the context of the experimental design otherwise they will be misrepresented as straight correlations. For instance, the article cites from a multiple of articles that epidurals increase the likelihood of instrument assisted labor, yet the author doesn't discuss, as the study must have, the nature of the experimental groups. For instance, many hospitals that administer epidurals will also administer labor inducing drugs in conjunction. This is true of episiotomy as well, since women with pain management are often not consulted and don't even feel the incision. One must ask what is the intent of the scientific investigation? Were the researchers concerned with actual risks/benefits of said procedure, or were they merely attempting to report on the common practices associated with the procedure (Follow me here...). One can either investigate cause/effect of something, in which experimental design is critical, or one can investigate common associations with something, in which experimental design isn't relied on as heavily, in order to establish associations for further investigation. Without an explanation of the experimental design and intent of the research one is left to guessing what the intentions of the researchers may or may not be. And without a summary of the discussion/conclusions of the experiments, then one can't further apply the results and give weight to them.
Again while I would agree that it is useful to compile such a list of pro/cons based on medical research, to dismiss the publications discussions on reasons why the correlations may be skewed is presumptious at best, and intentionally misleading at worst. I understand this isn't a publication, but I would hope that people would understand that these studies are only as good as the experimental units, and with most medical research that doesn't involve discrete case studies there will inevitably be weak correlations presented with the intention for further analysis to be done.
I think that it would be a benefit to people if the experimental designs of said studies were at the very least summarized so that people can better judge the merits of said correlation. As it is now, I have no idea if the researchers merely reviewed hospital records or sought to minimize as many external variables as possible.
-brad
RE: That sure cleared it up...not by Brandon :: NR9 :: on 08 November 2007
Results need to be reported in the context of the experimental design ... one is left to guessing what the intentions of the researchers may or may not be ... to dismiss the publications discussions on reasons why the correlations may be skewed is presumptious [sic] ... I have no idea if the researchers merely reviewed hospital records or sought to minimize as many external variables as possible.
No need to guess or presume, as I provided extensive references. In many cases the link is even to the entire article.
these studies are only as good as the experimental units, and with most medical research that doesn't involve discrete case studies there will inevitably be weak correlations presented with the intention for further analysis to be done
Agreed.
-brad
C'mon ... I know you have an account. :D
RE: That sure cleared it up...not by Anonymous :: NR0 :: on 09 November 2007
No need to guess or presume, as I provided extensive references. In many cases the link is even to the entire article.
I know the references are listed, I just object to displaying results without at least a sentence or two discussing the research methods of the study. I was merely offering critique. Would it have been so hard to add in the two or three sentences for each study to explain how the samples were gathered? And would it not provide the depth necessary to gage the weight of the results?l I understand that you put considerable effort into googling some research papers and I assume reading them, but it becomes difficult for me to rely on said results when there is no discussion of experimental method. For all I know you merely took the first 10 references that appeared on google scholar and then picked out the results and compiled them. Your right that I could go and search myself, but then what exactly would be the point of your paper? Other than to fact check it for you.
Again, please don't take offense, but the reason I replied in the first place is because I think what you have compiled here does a great disservice to your average layman looking for information. Not everyone on the web is capable/willing to read a scientific journal article and understand the results. For this reason, I assume, you sought to compile some literature and provide it as reference for others. But since you in no way discussed the experimental designs of the papers or even you criteria for accepting said results you have only really provided a tool that could be misused by many. Many could read your paper and assume that you knew what you were talking about when you compiled the literature and providing references isn't going to do anything for average joe, because average joe probably isn't going to be able to understand everything in said references. So for you not to even acknowledge experimental design raises a huge red flag to someone who does read scientific journals on a daily basis. I'm not trying to say that one of these studies is wrong, I don't know that having not checked references, but what I am saying is that if you don't at least give a synopsis of the goals of said study and the experimental design I have no way of knowing if the researchers were seeking to establish correlation, or if they were merely reviewing records to present trends that should be further studied. And that is a HUGE difference.
Do you understand my point about how merely citing something doesn't excuse one from placing the information into context? By citing you can mislead far worse. From a professional standpoint (and I am far more sensitive to this stuff because I am held to such standards myself) this is a big academic no-no.
-brad
RE: That sure cleared it up...not by Brandon :: NR9 :: on 12 November 2007
I can understand how the average Joe would have issues here, but he's not my intended audience - and rightly so, as Joe Schmoe would probably punch his monitor or browse to his favorite adult site before getting halfway through. The average Joe isn't interested in context or experimental design; he is completely satisfied with hearing (and likely accepting) "studies show epidurals can be dangerous" on his local news.
Others, however, want to know more. So, where do they go? If they were like me a couple of years ago, they'd spend hours trying to pick the best of search engine results. As I learned in the discussion following my soy milk article, however, there are better sources - more particularly, PubMed and the like. This article takes advantage of hours spent perusing and organizing PubMed results for recent research applicable to my topic: the pros and cons of epidural analgesia in labor/childbirth.
Those who want to know more now have the ability to access a good number of directly relevant studies - organized by year and with succinct results/conclusions presented - in minutes, rather than hours. The reader, such as yourself, looking for more context can move to the next step up: reading the cited studies' abstracts. Want even more? Read the studies in their entirety. Even more? Read the related studies (nicely listed on the cited websites).
My article is not a peer-reviewed publication (as this is not an academic journal), but it is coherent, organized, and serves its purpose: to provide those like me who want to know more with a convenient bridge from the everyday Google world to the academic world.
RE: That sure cleared it up...not by Anonymous :: NR0 :: on 12 November 2007
I guess we will just have to agree to disagree then, because as you put it, your target audience is of higher mental capacity, and I, a member of said group, find the article lacking an essential/critical element in it's composition. I agree that you put a lot of time/effort into researching your references, all the more reason for you to have commented on the nature of the experiments and the intended goals/conclusions of the researchers. What you have done is provided some references, categorized them, and displayed results without giving the reader any reason to trust your references. That's my point, you did yourself a disservice as well as the reader. This is an issue of polishing a summary.
The average Joe isn't interested in context or experimental design; he is completely satisfied with hearing (and likely accepting) "studies show epidurals can be dangerous" on his local news.
And you have done pretty much what most news organizations do, you present some results without context for people to interrupt them. And yes the local news provides references too, usually from PubMed or someother journal. Although, come to think of it, they usually describe the study.
My article is not a peer-reviewed publication
No, but someone reviewed it to be posted on Omninerd and that someone obviously thought well Brandon must know what he is talking about and since he provided references I don't need to question validity. Again, I'm not saying that the chosen articles are bad, but merely questioning the decision not to include a summary of the experiments so as to allow others to better weigh the facts.
..serves its purpose: to provide those like me who want to know more with a convenient bridge from the everyday Google world to the academic world.
But to draw any reasonable conclusions from your article without said summaries, the reader must check each of the sources him or herself. In essence you provided us with a list of your google scholar search results...albeit a little more tabular. But at least google scholar provides an abstract by which one can access the validity before clicking on the reference.
The reader, such as yourself, looking for more context can move to the next step up: reading the cited studies' abstracts.
This sums up my entire critique, with out an abstract/summary of the experimental goals the results are meaningless. They don't mean a thing if I don't know how/why they were obtained. Context is needed in everything be they peer-reviewed or not. You are passing along results without giving anyone the slightest idea of how they were obtained...you have vouched for them, and I don't think obstetrics is exactly your field of expertise. Maybe a Dr. could get away with out providing context, though he shouldn't, but why should you? Because you searched around for a couple of hours?
My question to you Brandon, is do you know what the experimental goals/methods of your references, or did you pull numbers from an abstract. You have given the reader no reason to suspect that your references are valid at all.
RE: That sure cleared it up...not by Brandon :: NR9 :: on 12 November 2007
without giving the reader any reason to trust your references
My intent was not to have them trust me. My intent was to organize and present the information I found so others could read the articles themselves, where interested, and then decide if they trust the researchers.
the local news provides references too, usually from PubMed or someother journal. Although, come to think of it, they usually describe the study.
That's not my experience. Recently, for example, I put up a news post linking to an article discussing two studies on oral contraception that have been in the news recently. I discussed a little about the article and provided a link to it - and it took me about 2 minutes. If you go to the article, you'll find a little more information on the studies themselves, some of the possible limitations, and even a couple of references (which is unusual for most news services). There aren't links to the studies, though, so someone wanting to know more about the issue would need to search them out on their own. This is what the news typically does. It provides their interpretation of the method and results of a study, quotes some researchers, and tries to make it interesting.
If I were to write an article on the "pros and cons of oral contraceptives: recent research," I'd include a link to the involved studies, as well as about 10 others on the subject - along with summarized results/conclusions for each - organized by year. As opposed to the news post above, this would take quite a few hours. It wouldn't much detail on the individual studies (which the reader could get straight from the horses mouth, anyway), but it would give a different sort of context - the context of other studies on the subject published over time. As I said before, it's not an academic journal publication - but it would keep the next person who came along from having to repeat the searching I did.
with out an abstract/summary of the experimental goals the results are meaningless
Right. So read the abstract/summary of the experimental goals. I gave you a link, you don't even have to look it up. ;)
you have vouched for them, and I don't think obstetrics is exactly your field of expertise
I haven't vouched for them because it's not my field of expertise.
Maybe a Dr. could get away with out providing context
A doctor could get away with providing context outside of what is in the linked articles/abstracts.
do you know what the experimental goals/methods of your references
I know what I could access for free. How much I know really is of no consequence here, though. I'm just providing the research of others in an organized fashion.
You have given the reader no reason to suspect that your references are valid at all.
Good. I hope they'll take the references on their own merit, not mine.
RE: That sure cleared it up...not by Anonymous :: NR0 :: on 13 November 2007
I'd include a link to the involved studies, as well as about 10 others on the subject - along with summarized results/conclusions for each - organized by year
No you provided results but you didn't provide conclusions because you didn't have access to them. You only had access to the abstract and that may or may not contain all of the results. My whole beed was that there was no summary of the conclusions of these studies since the conclusion of an article seeks to resolve experimental design and results. Do you think you provided conclusions?
Right. So read the abstract/summary of the experimental goals. I gave you a link, you don't even have to look it up. ;)
The abstracts you read didn't give a summary of the experimental goals, hence my critique. Depending on the journal, abstracts can be extremely limited. Abstract was a poor word choice in that context, I should have clarified.
You have given the reader no reason to suspect that your references are valid at all.
Good. I hope they'll take the references on their own merit, not mine.
So in your mind journalism isn't about choosing reliable, relevant sources, but rather about displaying any info and linking a source. How exactly is that better than your "bad news" example? If you think there is no responsibility on your part to provide accurate, relevant (and this is where experimental design is key) sources than you have no business posting anywhere reputable.
RE: That sure cleared it up...not by Brandon :: NR9 :: on 13 November 2007
[Y]ou provided results but you didn't provide conclusions because you didn't have access to them. Do you think you provided conclusions?
When I say conclusions I mean statements like "Epidural analgesia is a safe and effective method of relieving pain in labor." Results would include something like, "Inadequate pain relief during labor and during delivery were found in 5.3% and 19.7% of patients." The former draws conclusions from the latter.
If you're pushing some other definition of conclusions, then I think this has devolved into arguing semantics. The important thing here is if what I provided was misleading. (Although, I am interested why something labeled as "conclusions" in the abstract would be considered something other than conclusions...)
So in your mind journalism isn't about choosing reliable, relevant sources, but rather about displaying any info and linking a source.
Yes, good journalism is about providing reliable, relevant information - and I think the studies I included speak for themselves in this regard. Do you see one that isn't reliable/relevant?
How exactly is that better than your "bad news" example?
I didn't intend my example to represent bad news, but my article is different in just in the way I explained: extent of information provided, original organization/presentation, time to research, etc.
conclusions and discussion by bradsmith :: NR6 :: on 13 November 2007
If you're pushing some other definition of conclusions, then I think this has devolved into arguing semantics. The important thing here is if what I provided was misleading.
Have you read an article and then compared it to it's abstract? Conclusions in articles reconcile results with experimental design and experimental limitations. One can have a result that suggests one thing, but when take the limitations of the experimental design into account the authors usually cede the point that the results are interesting but need further analysis. Abstracts are often very misleading.
Yes, good journalism is about providing reliable, relevant information - and I think the studies I included speak for themselves in this regard. Do you see one that isn't reliable/relevant?
See my other post for those that aren't reliable/relevant. I really have this feeling that since you pulled papers off PubMed you feel that they are top notch and that you couldn't possibly have overstated the scope of the cited papers. Experience has taught me that a google scholar search won't give me articles that have all that much relevance to my work regardless of what the title may say.
I didn't intend my example to represent bad news, but my article is different in just in the way I explained: extent of information provided, original organization/presentation, time to research, etc.
The extent of info doesn't mean anything if it is misused/misrepresented. You can't have it both ways Brandon, you can't cite a bunch of papers and then deflect criticism saying I'm not responsible for those citations.
RE: conclusions and discussion by Brandon :: NR9 :: on 14 November 2007
See my other post for those that aren't reliable/relevant.
You made comments about two studies being exploratory, but I didn't mean to exclude such.
you can't cite a bunch of papers and then deflect criticism saying I'm not responsible for those citations
No, but I can cite papers and not be responsible for their content beyond my stated purpose. I take full responsibility for finding articles fitting my criteria as listed elsewhere.