Study Design for the New Millennium: Changing How We Perform
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New technologies seem to arrive al- most daily, and all of us struggle to keep pace. In the current issue of Radiology,. Hunink and Krestin (2) offer
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Editorials Jeffrey G. Jarvik, MD, MPH Study Design for the New Millennium: Changing How We Perform Research and Practice Medicine1 We live in a time of such rapid change and systematic data collection into daily new tests, but none of the aforemen- growth of knowledge that only he who is practice while allowing the monitoring tioned factors that lead to use of new in a fundamental sense a scholar--that is, of trends in decision making and out- diagnostic tests are reflected in measures a person who continues to learn and in- comes over time. such as sensitivity, specificity, or receiver quire-- can hope to keep pace, let alone While new diagnostic tools stream into operating characteristic curves. It should play the role of guide. Nathan M. Pusey (1) the medical marketplace, the actual ben- not be surprising that research "business efits are frequently difficult to establish. as usual" has resulted in the dissemina- The world of the radiologist is truly Hunink and Krestin cite the work of tion of new technologies before they changing rapidly, and it is often confus- Wright and Weinstein (3), who empha- have been adequately evaluated. ing. New technologies seem to arrive al- size that changing from an old to a new The authors (2) spend the first portion most daily, and all of us struggle to keep diagnostic strategy generally results only of their article discussing the assump- pace. In the current issue of Radiology, in small benefits to the patient. If this is tions underlying current methods of as- Hunink and Krestin (2) offer an approach the case, what is driving this frantic rush sessing diagnostic technologies. They to the rational evaluation of innovation for newer diagnostic techniques? Part of point out the lack of good reference stan- "on the fly" and guide us toward adopt- the answer undoubtedly lies in the minds dards, the biased assembly of cohorts, the ing new methods of practicing medicine of referring clinicians. Although new di- limitations of sensitivity and specificity in a sensible way. Theirs is a well-written agnostic tests may not make patients feel as metrics, the limitations of decision and thoughtful discussion of a problem better, they almost certainly make physi- analysis, and the difficulty of performing that researchers face on a continuing ba- cians feel better. We all fear uncertainty, large randomized controlled trials for as- sis. Hunink and Krestin propose not so especially if the health and well-being of sessing new diagnostic technologies. much new techniques for conducting re- patients depends on crucial decisions They also point out that information search but rather a new paradigm for the that we make in the face of such uncer- about a new test does not necessarily lead practice of academic medicine that inte- tainty. Having a new and seemingly bet- to optimal use. Pressure from referring grates random allocation of patients and ter test to confirm a diagnosis likely reas- clinicians and patients more often than sures physicians that they indeed have not results in a new diagnostic test being made the right decision regarding diag- performed in addition to, rather than in- nosis and treatment. This reassurance stead of, the existing test. But perhaps the Index terms: may even be transmitted to the patient, most compelling argument for a new re- Editorials although the effect that such reassurance search approach is that the extremely Radiology and radiologists, research has on currently used quality-of-life rapid pace of change in technology re- Radiology and radiologists, socioeconomic scales may be unmeasurable. There also sults in standard assessments frequently issues continues to be pressure for clinicians, as being out of date by the time they are well as radiologists, to remain au courant, disseminated. Published online before print 10.1148/radiol.2223011621 which often may translate into use of the The authors propose dispensing with Radiology 2002; 222:593594 latest technology. Marketing by manu- the evaluation of diagnostic accuracy and facturers also plays a role in the adoption instead focusing simultaneously on clini- 1 of new technology, although the magni- cian decision making and patient out- From the Department of Radiology, Uni- versity of Washington, Box 357115, 1959 tude of the effect has been poorly quan- comes. Their study design of choice is the NE Pacific, Seattle, WA 98195. Received Oc- tified in the clinical literature. Finally, let randomized trial. In the 19th century, tober 2, 2001; accepted October 8. Ad- us not forget that it is just plain fun to be Alphonse Karr, a French journalist, re- dress correspondence to the author (e- the first on the block with a new toy. marked, "Plus c¸a change, plus c'est la me^me mail: jarvikj@u.washington.edu). © Why do the Hunink and Krestin be- chose" (the more things change, the more RSNA, 2002 lieve that a new research paradigm is they remain the same) (4). As it turns out, See also the article by Hunink and Krestin in this issue. needed? Radiology research has tended the paradigm suggested by Hunink and to focus on the diagnostic accuracy of Krestin was used in nearly the form that 593
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