Definition of Terms

Content Rules
All of the external links on this site are to professional associations accountable to the public trust, or to recognized charitable organizations (who must have a medical advisory board) appropriately registered as charities, also accountable to the public trust. This does not mean that all information on such websites is completely up-to-date or accurate, since there is often wide disagreement within the medical community about various issues. But it reasonably ensures that blatant “spin” or fabrication does not occur on these links. We no longer link to patient-generated websites, bloggers, other private individuals, or pharmaceutical sites of any kind. Since this is also an author website, we DO link to all consumer health content generated by Dr. M. Sara Rosenthal, whose consumer books involve a medical review. All other content on this site has been peer reviewed.

Critical Thinking Skills
If you’ve seen the film, The Wizard of Oz, you have a good example of what critical thinking means. Who is the person “behind the curtain”? In this case, who is the person behind the information you’re reading? A few important questions are:

  • What is the copyright date of the material? Is it current? Health content offering prescriptive advice that is older than 5 years is usually substantially out of date. Descriptions of biological processes can even change as new understanding of various conditions becomes available, but it depends on the topic. A 10-year old book on pregnancy that describes the physical process of pregnancy will not be dated, but screening guidelines for gestational diabetes, for example, would be completely out of date. For content that involves a review of the literature, known as a review article (summary articles that look at “where have we been, where are we going”), older materials are very relevant. Material that discusses sociological, ethical, or other theoretical concepts does not date, and can remain relevant for decades. Material that discusses law and policy may be relevant for decades, depending on the topic.
  • What is the education, background and training of the author? Authors or journalists with no specific medical credentials are credible, so long as their content is put through a medical review. Ph.D.-authors who write about health content can be medical social scientists, medical historians, or basic science researchers. (Some of us Ph.D. authors are also bioethicists!) Of course, training is very important, too. Sometimes the Ph.D.-trained author has been through more rigorous training in academic critical literature, and is better situated to judge references and resources than MD’s who have had no training in academic medical research. Much depends on the CV! MD-authors may be biased if the content has not been peer-reviewed, but they are also more likely to have had a ghostwriter, which means that the content was generated by a professional writer who then vetted it by the doctor for review. In these cases, the doctor is the “author” of the book or website contractually, but has really played the role of medical editor. Some people who claim to have a Ph.D. received it through a non-accredited institution, or a sham operation online. That means they do not have a recognized doctorate but have used the credential on their materials to fool the public into thinking they have more education than they do.
  • Do you even know who the author is? If no one claims ownership over text you find online, its credibility is highly suspect.
  • How does the author/website profit from the information provided? For example, health guides on About.com get paid by the “hit”, which would require the guide to sensationalize content to draw in browsers. Some websites are completely sponsored by pharmaceutical companies. A website on erectile dysfunction that is sponsored by an erectile dysfunction drug will have a clear agenda: to sell the drug. However, the information may be accurate.
  • Are there products the author promotes, or advertisements accompanying the material? Does the author/blogger promote particular herbs or supplements (e.g. coconut oil) or brand names? This could be suspect unless these herbs/supplements are the standard of care.
  • Does the content make sweeping generalizations without proper references?
  • Does the author “editorialize” offering just opinion or an informed review, citing relevant literature.
  • Does the author base the information on “other people’s stories” (known as anecdotal or narrative)? If this is the case, then the information is probably not credible.
  • Does the content make potentially defamatory statements about someone: vexatious comments that are personal attacks are a sign that the author is very unprofessional and lacks credibility. People who can’t formulate intelligent arguments resort to name-calling and discrediting. (Note what goes on in the political arena.
  • Does the author disclose all relevant conflicts of interest? (Disclosing the relevant conflict, means the conflict has been ethically managed, so it is no longer a conflict.) To read more see below.

Critical thinking in the academic community applies a much more rigorous process, but the above is a good starting point for the lay-public at large.

Conflict of Interest
Be sure that you also understand what is truly a conflict of interest. Conflicts worthy of disclosure involve financial issues. Has the author's study or article been funded by a third party? Does the author personally receive more than 10% of his/her income from a particular source that is at all relevant to the content? Sometimes the conflict may be in the reverse: if the author stands to lose financially or politically because of what s/he has written, it is a sign that the author felt a moral obligation to "blow the whistle" and risk unpopularity for the sake of academic scholarship. Reverse conflicts of interest carry ethical weight in favor of the author. Researchers who merely participate in a professional meeting or lecture, sponsored by a pharmaceutical company through an unrestricted education grant, does not constitute a financial conflict of interest. Nearly all professional meetings are sponsored by pharmaceutical companies these days and provide the only forums in which to present research and work. Even grand rounds at universities are sponsored in this fashion.

Speaking fees and Honoraria: In general, a speaking fee (aka honorarium) is not considered a conflict of interest unless it represents a significant source of personal income to the author. Honoraria are designed to compensate a presenter for his/her time and travel expenses. The general rule of disclosure iis 10% from a single source. So if an individual earns $100,000 per year, and s/he is paid more than $10,000 per year by ONE source, it is worthy of disclosure. On the other hand, honoraria coming from ten DIFFERENT sources that total $10,000, are NOT considered worthy of disclosure.

Informed Decisions

Medical Review
A medical review means that an author with no formal medical training submits content s/he generates to one or two medical experts in the field for editing and corrections. A medical advisor is preferably an expert in the topic, rather than a “naturopath” or generalist (e.g. a family doctor) with no specific recognition in the field or topic in question. Sometimes this means the advisor is a nutritionist, or specially credentialed in a certain medical technology. The more specific the medical content, the more specially trained the medical advisor ought to be. If the topic is in the field of alternative medicine or natural medicine, than an appropriate medical advisor would be one who is a recognized expert in that specific area. Although the field of natural health is hard to credential, evidence of some formal training in these areas would be essential for such an advisor. When you see a health website run by someone with no formal medical training, or a book written by someone with no medical training, ask yourself if the content has been reviewed by someone with relevant medical credentials. If a patient-author writes a book, does the book go through a medical review? Acknowledgements or Forewords will often reveal who the expert reviewers were. If a website is just a “free for all” blogger environment, the website may be entertaining, but is probably full of inaccuracies. Content that does not need a medical review is health narrative (see below). Content that does need a medical review is content that describes health conditions and offers information on symptoms, treatment options, and specific research in that area, or reviews of the peer-reviewed academic medical literature.

Health narrative means that the health content being offered is clearly subjective, and is the story of one or many individuals experiences. This is an important type of health knowledge to share as it validates other health experiences. Health authors (e.g. patients) or bloggers who state that the content is “my story” need to be read within the appropriate context of a storyteller, but these texts are not to be misconstrued as prescriptive advice about a disease. Some websites or books mix narrative with “advice”. Many websites begin as narrative and expand into advice, without adding medical review to the “advice” portion of its text. All listserves should be considered health narrative. Many listserves have a medical advisor monitoring the content to ensure that narrative doesn’t cross the lines into advice; such advisors may jump in and send posts that correct potentially dangerous misinformation. Internet health browsers who don’t understand the difference between narrative and advice often base their decision-making on the subjective narratives they read, which may also quote from other sources (usually misconstrued as well). When you read: “I had a bad reaction to drug X” it is narrative. When you read: “I read in Journal X that herb Y cures disease X” it is narrative.

Misinformation
Misinformation means that some real facts are mixed with false statements, bias, misapplied contexts or concepts. It can also mean that one fact is wrongly linked to another fact to create a completely false statement. Here are some common examples:

Example 1: Laboratory research in cell culture misread as a legitimate therapy in humans. Lots of interesting results happen in laboratories that are years away from practical bedside application. “Bench” research is not the same as “bedside” research. Many articles are misunderstood in this manner. People may read that some chemical component of a particular food “delayed the growth of breast cancer cells” in cell culture, and then leap to the conclusion that everyone who eats this food will prevent breast cancer.

Example 2: Misconstrued conflicts of interest. Pharmaceutical companies are the source of funding for many kinds of research and educational conferences. These are called “unrestricted educational grants” which are fully disclosed on conference materials. The grants go to the professional associations to pay for the tremendous costs of putting on an annual conference that reports on the latest research in that field. Without educational conferences, physicians could not accrue Continuing Medical Education credits, keep up-to-date, and keep their licenses renewed. Researchers and clinicians who present at professional conferences are not “funded” by the pharmaceutical companies supporting the conferences, and are often not paid speakers. One web blogger got a hold of the Speakers list from one such conference and inappropriately listed all the conference speakers as being “personally paid and funded” by the pharmaceutical company. This is blatant misinformation that is also defamatory. It also exposes how ignorant the blogger is when it comes to understanding how academic conferences function.

Peer Review
Peer review means that content generated by someone trained in a special area is circulated to his or her academic or medical peers (who are similarly trained in a similar area), so they can comment on the content and point out errors, bias, distortions, or suggest improvements. That makes for more objective, accurate content. All academic journals are “peer-reviewed”. When academic articles are written, the author submits his or her article to the journal. The journal circulates to three or four academic peers, or peers who are experts in the topic the author is writing about. These peers critically assess the content and make recommendations as to whether it’s good enough to be published. Many publications submitted to journals are rejected; many are revised and resubmitted for reconsideration. This process helps to create content that is reasonably accurate and unbiased. It’s not a perfect process, but it’s the best “checks and balances” methods we have to ensure that work published in the academic forum is reasonable, well-referenced, and well-considered. When you see peer-reviewed literature discussed on patient-generated websites or listserves, ask yourself if the persons assessing these articles are “experts in the field” or are just basing their opinions on their own individual experiences. In other words, who ARE these people? Does health blogger X or “Mom with disease X” have the academic credentials, training, or critical thinking skills needed to really assess scientific or medical peer-reviewed literature? Is it reasonable to think that blogger X or “Mom with Disease X” has accurately interpreted the article? Only you can decide.