Letters to the Editor  |   October 2012
Holding Rhetoric to a New Standard: What's the P Value of That Statement, Senator?
Author Affiliations
  • Simon B. Zeichner, DO
    Department of Internal Medicine, Mount Sinai Medical Center, Miami Beach, Florida
Article Information
Cardiovascular Disorders / Evidence-Based Medicine / Medical Education / Obstetrics and Gynecology / Professional Issues / Graduate Medical Education
Letters to the Editor   |   October 2012
Holding Rhetoric to a New Standard: What's the P Value of That Statement, Senator?
The Journal of the American Osteopathic Association, October 2012, Vol. 112, 648-649. doi:
The Journal of the American Osteopathic Association, October 2012, Vol. 112, 648-649. doi:
To the Editor: 
“I want to administer an ACE [angiotensin-converting-enzyme] inhibitor for the patient,” the medical resident said confidently. 
“Ok, we can do that, but what evidence do you have for starting that treatment?” the attending physician countered. 
The medical resident responded, “According to the randomized controlled trials CONSENSUS,1 SOLVD,2 and SAVE,3 patients with congestive heart failure and a reduced ejection fraction, when given ACE inhibitors, have a statistically significant decrease in mortality compared with that of patients not given ACE inhibitors.” 
This typical exchange between a resident and attending physician in a hospital setting exemplifies how evidence-based practice has become the standard of care in medicine. Treatment practices and recommendations are not made on the basis of opinion, hearsay, or propaganda but on critically reviewed research and statistically robust evidence. 
Health care practitioners come to terms with the profound power of bias and its ability to influence ideas and decisions. Although not perfect, health care professionals have found an objective way to make treatment recommendations that address the welfare of patients. 
However, a culture of randomized controlled trials and evidence-based practice seems to be of little importance in politics these days. Every day, politicians voice their opinions with little regard to evidence, facts, or statistics. They base their ideas and decisions on deeply rooted beliefs, emotional swings, campaign donor opinions, and propaganda. They speak of war, regulations, taxes, health care, gun control, education, abortion, and environmental issues. There is no talk of type I or II errors, treatment variables, hazard ratios, standard deviations, lead-time biases, or P values. 
A detractor might protest that medicine is different from politics because in medicine, patient health is at stake. Despite seeming incidental, political statements and laws, I assert, also affect peoples' health. An individual's quality of life, number of hospitalizations, morbidity, and mortality—measures often used in medicine—are measures also affected by political rhetoric and policy. Who is to say whether the decision to go to war, the decision to have no gun-control laws, the decision to cut funding, or the decision to deny universal health care are in fact improving the population's quality of life and decreasing its overall morbidity and mortality? These are matters that need to be studied with empirical research. 
Why aren't politicians held to the same rigorous standard as health care practitioners? Why aren't politicians pressed to prove everything they say with hard evidence? 
Perhaps one day we will see the following exchange:

Senator: “Ok, I propose XYZ for the country.”


Reporter: “Ok we can do that, but what statistical evidence do you have?”

The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure: results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med. 1987;316(23):1429-1435. [CrossRef] [PubMed]
Pouleur H, Rousseau MF, van Eyll Cet al. Effects of long-term enalapril therapy on left ventricular diastolic properties in patients with depressed ejection fraction. Circulation. 1993;88(2):481-491. [CrossRef] [PubMed]
Pfeffer MA, Braunwald E, Moyé LA, et al.  on behalf of the SAVE investigators. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: results of the Survival And Ventricular Enlargement trial. N Engl J Med. 1992;327(10):669-677. [CrossRef] [PubMed]