Is orthodontic research poor? The Pyramid of Denial revisited
This blog post is about the rejection of research findings. I have decided to revisit the ‘Pyramid of Denial” which outlines the reason for illogical rejection of research.
One of my earliest blog posts was about a lecture that I gave at a symposium on early treatment. As part of my presentation I discussed the reasons that people put forward when they rejected or ignored research. I based this on feedback from questions that people asked at lectures, social media discussions and corridor conversations with the “great and good” of orthodontics.
Firstly, I would like to point out that I am not encouraging the blind acceptance of all research findings. We also need to remember that evidence based care is not solely based on the results of clinical trials.
However, I would like to discuss the rejection of findings in the absence of a proper critical appraisal. This led me to propose the Pyramid of Denial.
Lets have a look at the levels of denial
I know best
This means that a person feels that despite the evidence from the research project, they simply do not agree with the findings. In effect, they have decided to prioritise their clinical experience over the research findings.
We know best
This is when a group of people ignore the evidence and put forward a rebuttal. Again, this is often based on clinical experience or
financial other influences?
You should have asked us?
I first became aware of this reason when we published the results of our studies into Class II treatment. Several “orthodontic authorities” told me that the results of the trials were disappointing and it was a real shame that we had not discussed the treatment with them. They felt that we had made mistakes in the design of our appliances and choice of mechanics. For example, someone told me that the Twin Blocks we used did not work because of the design of the lower molar clasps.
In some ways they were pointing out that the studies were subject to proficiency bias. However, when we set up the studies we agreed as a group on treatment protocols. We also held courses on the use of our appliances.
These comments are often about made about trials, and while they may be valuable, we should interpret these with caution.
You did it wrong?
They suggest that the study was simply flawed. We know that the publication of a study does not always guarantee that it is good. As a result, we need to use our scientific knowledge and interpret the findings with respect to methodological errors. I hope that this blog and other methods of critical appraisal can help with this.
Unfortunately, people propose spurious reasons for the rejection of research findings. For example, they feel that their preferred outcomes were not measured. They may also suggest that there are no outcomes relevant to the treatment that they provide. Interestingly, this is becoming more common with the discovery of orthodontics to cure breathing problems. Most orthodontic trials do not include measures of breathing and perhaps investigators should include these, if only to answer the “orthodontic breathing physicians” points.
A common criticism of trials is that the participants are treated “like a number”. Consequently, treatment is so tightly prescribed that care cannot be individualised. In effect, the investigators are not evaluating the “art of orthodontics”. I strongly feel that this is incorrect. We need to remember that the operators in a trial are ethically bound to treat the patient to the best of their ability. This means that they adapt their mechanics to provide optimum care. This also ensures that the study has external validity. Furthermore, it would not be ethical to treat a patient exactly to the study protocol if they recognised that they were doing harm.
My patients are different
The person rejects the findings because they are not applicable to their patients. This means that their patients are so different that they are genetically, sociologically and morphologically different from those in the trial. There is little to be said here..
Pyramid of denial bingo
Sometimes when I look at these comments on a study. I play a form of bingo and count the number of time that the levels of denial are stated. I cannot help feeling that there is a positive association between the “denial” score and the level of quackery.
Lets have a chat about this..
Emeritus Professor of Orthodontics, University of Manchester, UK.