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Correcting Kid Logic in Health Care and Research DesignA recent broadcast on public radio described a fascinating phenomenon known as kid logic. It recounted how a young boy who had frequently watched takeoffs from various airports finally had his first opportunity to actually board an aircraft and experience a takeoff as a live passenger. As the plane gained altitude, he turned to the person next to him and asked, "When do we get smaller?"1 Totally reasonable and logical from the kid's previous limited perspective on the ground, but a totally absurd question once a fresh and necessary point of view has been provided. (Other less elegant constructs of kid logic, including the Tooth Fairy, Santa Claus, boogeymen and the like, need not be covered here.) Kid Logic Applied to Adult Science: A History Lesson It isn't much of a stretch at all to turn to scientific thought as expressed by full-blown adults. Consider a few choice and well-known examples: 1. Geocentric universe: As with the airplane-obsessed young boy, earthbound observers going back to at least 600 B.C. figured that all celestial bodies must necessarily revolve around their home planet. Ptolemy put the icing on the cake by fitting what he considered to be scientific evidence to preconceived and obviously limited notions, focusing on the retrograde motion of Mars and coming forward with a formal scientific theory. Although Copernicus raised the first serious challenge to this way of thinking in 1543, it wasn't until Galileo came forth with more robust evidence in 1611 that geocentric concepts were finally overthrown.2 2. Phlogiston: Introduced by Johann Joachim Becher in 1667, phlogiston theory stimulated that a tasteless, odorless, massless entity existed within matter that was released during combustion. Cessation of burning of a substance in a closed container was explained by the fact that the air in the container became saturated with the released phlogiston. It was nearly a century later that Mikhail Lomonosov offered the experimental demonstration that burned metals gain in weight, contradicting the expected removal of phlogiston from the metal. Modern chemistry subsequently provided the principle of oxidation.2 3. Miasmatic theory of disease: Up until the late 1800s, diseases such as cholera or the Black Death were believed to be caused by a miasma (Greek for "bad air"), identifiable by its foul smell and a poisonous vapor carrying particles from decomposed matter that produced illness. Although not so far off the mark in retrospect and conceived in good faith,3 it was eventually replaced by the germ theory of disease developed by Louis Pasteur and Robert Koch. 4. Stress theory of ulcers: With increasing demands experienced through the 20th century, doctors more and more believed that stress was the leading cause of peptic ulcers.3 A variant of this theory, which in retrospect brings a smile to the most jaded, suggested that ulcers could be traced to dominant mothers and passive fathers.4 It wasn't until 1967, when Barry Marshall ingested cultures of Heliobacter pylori, developed gastritis and re-isolated the pathogen after an endoscopy and biopsy, that he proposed that the cause of ulcers could be traced to a bacterium, following Koch's postulates to the letter. 5. Environment and autoimmune disease: As the German philosopher Georg Wilhelm Friederic Hegel stated, a synthesis arises from a thesis and its antithesis. In much the same manner, modern concepts of autoimmune disease have suggested that it arises from the environmental factors of infectious agents, toxic chemicals and dietary proteins.5 In other words, in some ways it appears to be a blending of items #3 and #4 above, and refines earlier concepts of illness. Applying the Same Standards to Health Care and Research Design Considering this progression of examples toward more enlightened models of health, we can't lose sight of the fact that the same holds true for concepts of health care and designs of health care research. Improving health care from the singular vantage points of randomized, controlled trials or case studies alike is essentially no different from our previous example of the small boy wondering when he will get smaller with the gaining of altitude as an airline passenger. It is simply a function of the observation post from which one views the world. Obviously, a multiplicity of as many perspectives as possible is needed, which is why such progressive concepts as pragmatic clinical trials,6 practice-based research,7 whole-systems research,8 comparative effectiveness research9 and prompted optional randomization trials10 have come into being to address the limitations of traditional randomized clinical trials.11-12 On a larger scale, it is imperative also to admit the basic sciences, cost-effectiveness,13 and psychosocial14 and psychoneuroimmunological15 research designs into the evidence base of medicine so as to provide those multiple vantage points that are prohibited by the traditional hierarchical pyramid of evidence.12,16-17 Finally, we must approach the field of chiropractic itself. With new treatises having survived peer review on such diverse areas as cost-effectiveness,13 applied kinesiology,18 neuro-emotional technique,19 sacro-occipital technique,20 acupuncture and cognitive behavioral therapy,21 it is time to recognize these areas as prospective adjuncts to chiropractic requiring research at chiropractic institutions and other accredited academic centers, if the full potential of chiropractic as an emerging conservative intervention for a variety of conditions is to be embraced. Otherwise, we will remain immobilized in the quagmire of kid logic. References
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