The road not taken

British Medical Journal, Oct 7, 2000

In his poem "The road not taken," Robert Frost is confronted by two diverging roads: "I took the one less traveled by. And that has made all the difference." We all wonder about the roads we haven't taken and sometimes we are tearful on the roads we have taken. Roads not taken and roads that should not have been taken are prominent in this week's BMJ.

Silvio Garattini and Alessandro Liberati deplore the bias introduced into medical knowledge by research not done (p 845). "Should we," they ask, "be more concerned about `bias caused by omitted research' than the well recognised pitfall of publication bias?" Economic incentives distort the research agenda. Trials are conducted mostly by drug companies. They do little research into tropical diseases--yet these diseases affect millions. They avoid doing trials that include children and elderly people--yet these are the groups whom doctors see the most. There is no economic incentive for the companies to do trials that compare drugs--yet doctors need to know which drugs are most effective. Garattini and Liberati want more independent trials.

Tony Delamothe is concerned, in contrast, with a road being taken wrongly (p 843). Many bodies--including the European Union--are interested in kitemarking websites that provide medical information. Too many of them, busybodies worry, are providing harmful information. Why all this concern? asks Delamothe. We don't feel the need to specify that newspapers, books, magazines, and radio and television programmes have met standards for correct information--yet many contain misinformation. This looks like the familiar fear of the new. Kitemarking the internet, argues Delamothe, is like trying to kitemark the west wind. His final advice applies in many circumstances: "Don't just do something. Stand there."

"Knowing how way leads onto way," Frost doubts the possibility of ever coming back. This is particularly true of information technology, and keeping your options open as long as possible should be a principle of all projects. Justin Keen and Jeremy Wyatt argue that a dedicated network for the NHS may have been the wrong road to take (p 875). Social trends can also be difficult to reverse, and a news story describes how insistence on the importance of consent from the General Medical Council may destroy cancer registries (p 849). Ironically, this is happening just when registries will be needed to underpin a new national plan for cancer (p 850). Judith Strobl and others discuss how uncertainties in data protection and confidentiality are also undermining research efforts (p 890).

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