Learning From the Extremes in Medicine

“The extremes inform the mean, not vice-versa”‎ – Timothy Ferriss

To the benefit of society, randomized controlled trials have formed the cornerstone of modern medical information. These types of trials have been instrumental in helping us characterize the best treatments for a number of diseases and conditions, improving healthcare quality overall. To make these studies applicable to the largest possible population, they are designed with very specific inclusion and exclusion criteria, which remove the atypical and extremes in order to formulate the best possible “average patient”.

However, in daily practice, a significant number of patients do not fit the criteria for being average. Despite not having a well-defined best therapy, these patients still need to be treated.

One of the most important parts of being a specialist in any field is knowing what to do when atypical or extreme situations arise. While the focus of most data available will be on the first, second, and third line therapies for the average patient, what really defines the experts among experts is knowing what to do in the most difficult situations.

This type of knowledge comes from three different sources. The first is experience, that for obvious reasons, takes years to develop. The second is by communicating with people with more expertise than yourself, which is made easier in the world of email and social media, but is still often limited to fairly specific questions.

The third option, which I find particularly high yield, is reading quality case reports and series in the literature. This portion of the literature allows you to actively seek out extreme situations and learn from them, which often have been written to summarize whatever data is available for guidance, often drawing on data from the more usual studies. As an added bonus, these articles usually end up being fairly interesting and memorable (or maybe just less likely to put you to sleep at your desk).

So, while it is always going to be important to keep up with the usual landmark trials in medicine, if you really want to separate yourself as an expert, you have to seek out the extremes.

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  • Great post. I couldn’t agree with you more. There are so many people who are excluded from randomized control trials and none of those at the extremes of medicine with rare diseases or complex co-morbidities will get into trials. The danger is that as journals downgrade case report to letters or very brief reports the level of detail so useful to the clinician will be lost.