Lore in the literature

“Lore: traditional knowledge or belief”

Let me say at the outset that by lore I mean information whose validity is not confirmed. Lore is a version of “truthiness,” as Stephen Colbert would say. Most physicians are familiar with the concept of “chart lore.” Chart lore is information that somehow found its way into a patient’s medical record and is perpetuated as factual even when it is not. We have all stumbled across this phenomenon. There is the patient who supposedly has had “congestive heart failure” for the past five years. When their echo report of five years ago from southern California is finally located, it is completely normal. Their dyspnea is actually due to reactive airways disease. Or the patient “hospitalized for a stroke” eight years ago. When someone finally retrieves the medical records from that time, it turns out the patient had only an ED visit for dizziness due to BPV. The ED physician might have mentioned to the patient she wanted to rule out a stroke, which lodged in the patient’s mind as what he had experienced. In fact, the patient was not hospitalized and had no stroke. But the diagnosis “history of stroke” has continued in the chart.

Lore in medicine is not limited to individual patient’s medical records. Regrettably, there is also lore in the medical literature which can have a very long half-life before it finally disappears into the sunset. At this point, I want to unambiguously say thank goodness for psychiatrists. Among all specialties, they are perhaps the most dedicated to honest self-inspection and self-disclosure. It is, after all, their stock in trade. So it is not surprising that psychiatrists were among the first to fess up. A recent article in Biological Psychiatry identifies an item of literature lore which has persisted in the psychiatry canon for some time, despite significant scientific questioning. The lore in question is the belief that there is a connection between the short allele of the serotonin transporter promoter and negative emotions. One study showed such a correlation. Despite a number of subsequent studies debunking this association, the results of the one positive study have been cited over 1,000 times as valid in the psychiatric literature. So the belief persists, even to this day.

What is the take-home message here? Even in the medical literature, once a mistaken idea gets entrenched, it can be difficult to dislodge. This problem is not unique to the psychiatric literature.

And what are practicing physicians to do? We need to be very careful about single studies which seem to prove a concept as valid, when subsequent studies show the contrary. I would also add that, hopefully, journal editors and publishers will redouble their efforts to avoid perpetuating literature lore, since busy physicians should not have to sort the wheat from the chaff while reading journals. Our time to catch up on new developments in our respective fields is limited and precious, and we need some degree of assurance that those working full time to offer us medical facts are careful stewards of science.

And on that note, I will dismount from my high horse.

Richard Fleming, MD

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>