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Wikipedia talk:Reliable sources (medicine-related articles)

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[edit] Question about a journal

If anyone wants to comment or has some insight, I've a question about the Journal of Mental Health over at RSN. WLU (t) (c) Wikipedia's rules:simple/complex 14:33, 26 May 2009 (UTC)

I usually pester User:DGG about questions like that. WhatamIdoing (talk) 00:21, 27 May 2009 (UTC)
Publisher is T&F, a good but second level academic publisher. The editor in chief and about half the editors come from a single department, often a danger sign, but it's the Institute of Psychiatry at Kings College London, which is rather well known. . However, it's not in Journal citation Reports, although indexed by Web of Science, it is not in JCR, and has published an article trying to explain why its important anyway. This is a serious indication that there are problems. DGG (talk) 04:50, 29 May 2009 (UTC)

[edit] Talk:Aspartame controversy#Air Force alert needs verifiable & reliable source

I have posted this at the RS/N, but want to make sure the medical matters contained are addressed by readers here. I have concerns about the way a source is being used. The way it is being used is consistent with the way it has been used in internet conspiracy theories regarding the supposed myriad dangers of aspartame, but I believe it grossly misrepresents the nature of the original source. I would appreciate more eyes on the matter. This is a medical and scientific matter, so to some degree WP:MEDRS would apply to any interpretation of the scientific matters discussed in the source. The original source seems to bear evidence of being influenced by the fringe conspiracy theories, while fortunately noting the mainstream POV from governmental and medical sources. -- Brangifer (talk) 04:27, 28 May 2009 (UTC)

[edit] Medicinal clay

The very new Medicinal clay article is in need of a thorough checking. Lots of undoumented claims are made. -- Brangifer (talk) 04:47, 1 June 2009 (UTC)

[edit] Expansion: CDC's website?

Under WP:MEDRS#Websites, could we mention some of the major government websites, like the CDC? We have ongoing problems (e.g., this) with people insisting that only peer-reviewed journals are acceptable. Perhaps a mention of major (international?) charities would also be appropriate: they often have decent statistics and can be accurate sources for statements about whether a treatment is common or only used for refractory cases, etc. WhatamIdoing (talk) 15:49, 4 June 2009 (UTC)

Clearly the CDC website is a reliable source, so I was bold and added that to WP:MEDRS#Websites. Charities are a bit iffier, as some have axes to grind. Perhaps wording about them could be proposed here? Eubulides (talk) 16:56, 4 June 2009 (UTC)
I was hoping someone else would have a brilliant idea about how to address that issue. I've also been thinking about the advantages of "permitting" these websites (as if this really trumped WP:RS), but still "recommending" medical textbooks or high-quality reviews. The hardy folks that deal with fringe topics are not going to be happy to have anything that suggests that www.QuacksRUs.org is a good source for medical information. Perhaps a restatement of not using websites to debunk the literature would be in order. WhatamIdoing (talk) 21:57, 4 June 2009 (UTC)
Statements and information from reputable major medical bodies (CDC, NIH, WHO, Institute of Medicine, etc) should obviously be considered valuable encyclopedic sources. One would hope that common sense would be sufficient to enable appreciation of that point, but apparently it needs to be codified.

Sadly, there is no language that will completely prevent some of our fellow editors from trying to sneak www.associationforsnakeoilstudies.com or rife.org into the encyclopedia under the same aegis as the CDC. I would suggest wording along the lines of "information from reputable major medical and scientific organizations may be a valuable encyclopedic source." If we reach the point where the words "reputable major scientific organization" have lost their meaning, then it's time to abandon this ship anyway. MastCell Talk 22:55, 4 June 2009 (UTC)

You mean like Australasian_Journal_of_Bone_and_Joint_Medicine? J/K ;) Unomi (talk) 02:59, 5 June 2009 (UTC)
I don't see the relevance to this discussion (assuming your comment had some intent beyond scoring cheap points). That journal was not a "reputable major scientific organization". It was a journal, and an obscure, low-profile one at that. Hopefully our existing guidelines would have led editors to properly weight material from that journal. On the other hand, sometimes shit happens. Wikipedia policies can't prevent real-world misdeeds. If someone had cited articles by Jayson Blair from the Times before his fabrications were revealed, it wouldn't make them a bad editor, just someone who was taken in like everyone else. MastCell Talk 03:34, 5 June 2009 (UTC)
I suspect that "J/K ;)" means "Just Kidding ".
Perhaps we should list the NIH, WHO, IOM (any others?) as examples. Would anyone object? WhatamIdoing (talk) 00:34, 12 June 2009 (UTC)
That sounds reasonable; I've proposed that in #Proposed rewording for Websites section below. Eubulides (talk) 07:25, 12 June 2009 (UTC)

[edit] Proposed rewording for Websites section

Looking at it another way, the word "Websites" in the section header WP:MEDRS #Websites is problematic. Whether info is on a website is reasonably independent of how reliable it is. After all, JAMA is a website, and it's generally reliable. Even medical books are now commonly accessed via websites. So I propose the following change, along the lines suggested above (and with some wording shamelessly stolen from MastCell's comments):

  • After Books, insert a new section Medical and scientific organizations with the following contents:
"Statements and information from reputable major medical and scientific bodies may be valuable encyclopedic sources. These bodies include the U.S. National Academies (including the Institute of Medicine and the National Academy of Sciences), the British National Health Service, the U.S. National Institutes of Health (including the Centers for Disease Control and Prevention), and the World Health Organization. The reliability of these sources range from formal scientific reports, which can be the equal of the best reviews published in medical journals, through public guides and service announcements, which have the advantage of being freely readable but are generally less authoritative than the underlying medical literature."
  • Change the title of Websites to be Other sources, and make the following changes to its contents:
"Internet websites Press releases, blogs, newsletters, advocacy and self-help publications, and other sources contain a wide range of biomedical information ranging from factual to fraudulent, with a high percentage being of low quality. Peer-reviewed medical websites information resources such as WebMD and UpToDate, along with websites of government health organizations such as the CDC, can be useful guides about the relevant medical literature and how much weight to give different sources; however, as much as possible Wikipedia articles should cite the literature directly."

Eubulides (talk) 07:25, 12 June 2009 (UTC)

I would specifically add both the professional [1] edition of the Merck Manual,DGG (talk) 04:17, 16 June 2009 (UTC)

Seems a very good change.--Garrondo (talk) 07:15, 16 June 2009 (UTC)

Looks good to me. Tim Vickers (talk) 16:06, 16 June 2009 (UTC)
I'm not sure we need to add this: ideally, if those sources have useful info, they are already included as sources for the article (which I see has been suggested in Eubulides' wording). (And the Merck Manual has long been woefully inaccurate on Tourette syndrome). SandyGeorgia (Talk) 16:05, 16 June 2009 (UTC)
Are the 3 comments above specifically about The Merck Manuals, or about the other proposed changes? Anyway, surely any mention of The Merck Manuals belongs in Books, not in the proposed Medical and scientific organizations or Other sources sections. Also, Books should be changed anyway, to make it clear that it talks about both online and printed medical texts. How about if I make a separate proposal for Books, which mentions The Merck Manuals and also mentions that many books are online? Eubulides (talk) 17:56, 16 June 2009 (UTC)
(Change proposed in #Proposed rewording for Books and Formatting citations below.) Eubulides (talk) 21:02, 16 June 2009 (UTC)
I really dislike the idea of endorsing the Merck Manual ... does anyone have the most recent version to see if it's still inaccurate on TS? And we shouldn't be encouraging adding anything to external links; ideally the sources are cited (can Eubulides' wording go further to state that?). SandyGeorgia (Talk) 18:00, 16 June 2009 (UTC)
The Merck Manual's entry on Tourette's is online and free. I haven't read that entry carefully, but it hasn't been revised since 2005 and anyway it is pretty terse, so it wouldn't be a good source for the Tourette syndrome article regardless of any factual errors. I just now read the Merck Manual's autism entry, which is pretty good: it has a few minor errors and is a bit dated despite its 2009 revision, but overall it would be suitable as a reference for the Autism article (if Autism weren't already citing better sources). Overall The Merck Manuals seem to belong in the Books section, which already comments on such such books' terseness and incompleteness, and their problems with being up to date. Eubulides (talk) 21:02, 16 June 2009 (UTC)
Just to clarify: this is about what is considered acceptable as a proper <ref>erence, not as an ==External link==. We do occasionally run into people that have a problem with major websites, including, e.g., a long conversation about the symptoms of swine flu, because they aren't peer-reviewed journals. WhatamIdoing (talk) 20:07, 16 June 2009 (UTC)
oopsie :) SandyGeorgia (Talk) 20:09, 16 June 2009 (UTC)

[edit] Proposed rewording for Books and for Formatting citations

How about this change to Books, to mention online books and The Merck Manuals?

"Many medical books are published online, and some, such as The Merck Manuals, are updated regularly. Ensure the book is up-to-date, unless a historical perspective is required."

While we're at it, Formatting citations should probably give an example of a book. Something like this, perhaps?

"A book citation should mention which chapter or entry of the book is being sourced. It is good practice to mention the date, authors, and (if available) DOI for the individual book component, along with the ISBN or OCLC number for the overall book. For example:

Eubulides (talk) 21:02, 16 June 2009 (UTC)

No further comment, so I installed the proposed changes. Eubulides (talk) 19:09, 22 June 2009 (UTC)

[edit] Casting it in stone

When considering studies for inclusion in clinical articles, I have usually kept a rule of thumb that phase II trials need to be absolutely earth-shattering to deserve inclusion. Even phase III trials need to be included with caution, because their findings don't necessarily mean that a procedure or substance will ever be used in a widespread fashion.

I was wondering if there was any scope for anchoring this rule of thumb into this guideline. After all, this applies to all medicine articles. JFW | T@lk 18:35, 21 June 2009 (UTC)

It seems you not only keep that rule of thumb, but have already generalized it to all other medical editors in the encyclopedia, as your recent edit summary shows ("there is longstanding consensus not to include phase II trials unless their results are absolutely earth-shattering"). You probably won't be surprised that I don't share this "consensus". Considering that consensus means general agreement within a group, and considering how small our group is, even a single disagreement rules out the word consensus. It's interesting that you provided no argument. I think most medical editors would disagree with your opinion. Clinical trials are not common for a fair amount of things. I imagine that many interventions don't even get to Phase III clinical trials. Should we make a rule where we keep out all negative evidence? Suggestive epidemiological and animal evidence can be, and often is, encyclopedic -- so why would actual controlled human data be non-encyclopedic? II | (t - c) 19:24, 21 June 2009 (UTC)
Could you please take my post at face value rather than trawling my edit history? Also, please let other editors speak for themselves rather than putting words in anyone's mouth.
A phase II trial is, by its very definition, a small trial in diseased subjects and the first to evaluate for effectiveness. Very large numbers of treatments don't even make it out of the laboratory, and even then a large proportion is not developed further if there are no encouraging results at phase II-III level. It is therefore impossible to say that a treatment is "promising" even if phase II trials are positive, because they may still die before being marketed, let alone implemented widely.
I was referring specifically to clinical articles. I think it would be utterly dangerous if we started listing all agents being trialled currently in Alzheimer's disease, for instance, and create the completely erroneous impression that dementia is a treatable disease. Wikipedia should not be in the business of promoting treatments that have no certain future. I cannot understand how you could actually disagree with this premise. JFW | T@lk 04:17, 22 June 2009 (UTC)
Generally speaking, I think that such a rule could be created and would be widely supported, although I think it would require more than a single sentence to properly explain the limits. For example, are we talking about this standard as applied to a disease article, or in an article about an investigational new drug? Is this information under ==Treatment== or under ==Research directions==? Are the rules different for rare diseases? For diseases that currently have no adequate treatments?
Additionally, are we sure that this the right guideline for such a recommendation?
As for the timing: I think that the vast majority of improvements to Wikipedia's guidelines stem from someone seeing an actual problem. I'd be unhappy to discover that someone sat around thinking up hypothetical problems to "solve" in the guidelines. That path leads to needless WP:CREEP and to guidelines that do not address editors' real needs. WhatamIdoing (talk) 04:45, 22 June 2009 (UTC)]]
Wikipedia already documents the substances undergoing clinical trials for Alzheimer's disease. The article is called Alzheimer's disease clinical research. In a highly-developed article like Alzheimer's disease, yeah, I can see why you wouldn't mention Phase II clinical trials. In less highly-developed articles like pancreatic cancer, the argument is less convincing. My rule of thumb is that most information can be presented on Wikipedia, although much of it should be presented in subarticles. II | (t - c) 05:38, 22 June 2009 (UTC)
Wouldn't it be better to try to educate readers what the ramifications/limitations of the different phases are? Then clearly state that it is a Phase II clinical trial. I think that our goal should be to enlighten readers. There are no space limitations, and it would be a mistake to write an article with a 'message' in mind. Unomi (talk) 07:19, 22 June 2009 (UTC)
This is an issue of WP:WEIGHT rather than an in-or-out global rule. As WhatamIdoing says, rare diseases with no current effective treatment might well warrant the mention of any promising, solid research. I don't see what the pancreatic cancer article being less "highly-developed" has to do with it. WEIGHT is more of a content than a sourcing issue. I'm sure there is more we can say about balancing content wrt medical aspects. WP:MEDWEIGHT anyone? Colin°Talk 08:18, 22 June 2009 (UTC)

I think ImperfectlyInformed's reaction illustrates the need for guidance on the inclusion of phase I/II trials. This is not a current major issue but it happens constantly in numerous articles, sometimes driven by media reports and sometimes driven by editors who have read something in a journal and find it highly fascinating and surely worth including. More is not always better; this applies to huge topics such as Alzheimer's but I can't see why pancreatic cancer (which receives a fair bit of research attention) doesn't fall under such guidance. Again, just because a very small trial has found some marginally interesting results for "some scary illness" doesn't automatically mean we are including it, because in the larger subsequent studies such effects may well regress to the mean or shown to be marred by toxicity. I can say with confidence that many of the drugs in Alzheimer's disease clinical research will never hit the shelves. What was then the purpose of giving them so much airtime? JFW | T@lk 14:15, 22 June 2009 (UTC)

Ideally, I'd like to see this handled flexibly. In general, I do think we give too much weight to the latest abstract from ASCO, but that is a failing of the popular press as well, so it's difficult to break free of it. On the one hand, whenever a new study piques interest and gets written up in the popular press, someone will reliably add a lengthy segment about that study to Wikipedia. We should probably discourage this, because of WP:NOT#NEWS, recentism, etc.

On the other hand, the evidence base for specific medical practices varies widely. In some areas (pancreatic cancer being an example), interventions are often adopted wholesale on the basis of very limited data, and Phase III trials may or may not ever be done (certainly the impetus for a drug company to fund such a trial evaporates rather quickly once their drug becomes de facto standard-of-care).

Basically, our articles should be in line with respected, expert medical thought and opinion, since our goal is to produce a serious and respectable reference work. If such opinion is based on Phase II trials, then it would be OK to cite them (hence I can't really get behind a cast-in-stone prohibition). On the other hand, we shouldn't be emphasizing the latest, greatest preliminary result at the expense of a balanced treatment of a topic. It might be OK to have a section in an article like pancreatic cancer where we discuss areas of active investigation - preclinical work and early Phase I/II results - with the clarity that this is the cutting edge and may or may not pan out. That would probably do readers a service - by informing them of current avenues of research - without misleading them into thinking that a single-institution, uncontrolled Phase II abstract definitively represents the wave of the future. MastCell Talk 18:31, 22 June 2009 (UTC)

  • It's definitely not a black-and-white issue. For a well-researched area like pancreatic cancer, though, it should not be hard to find reliable sources that review experimental and research therapies, and Wikipedia articles should rely on these secondary sources instead of citing primary sources directly. There are exceptions for groundbreaking primary sources that have not had time to be reviewed yet, but these exceptions should be quite rare (and shouldn't last longer than a few months).
  • This particular case does not seem to be an exception to the rule. Dhillon et al. 2008 (PMID 18628464) is a reasonable primary source on one relatively narrow topic, but it has been reviewed multiple times (notably by Fryer et al. 2009, PMID 19442075), and Wikipedia should be citing these reviews, not the primary source.
  • For rarer diseases such as (say) wandering spleen, primary sources may be the best we can do, and in that case they're OK.
  • The Assess evidence quality section already comments on evidence-quality rubrics, and perhaps advice about phase I/II trials could be folded into there. However, that section is already problematic, as it simply gives rubrics for assessing evidence quality, without making it sufficiently clear what the rubrics are for. When I first read that section, I misunderstood it to mean that Wikipedia editors should be using phrases like "Class IIIb evidence" in articles to summarize primary studies that articles cite, which (I hope!) was not the intent.
  • I'm dubious about encouraging jargon like "Phase II clinical trial" in articles on diseases or therapies. Medical articles should avoid jargon like that. The main text of articles should concentrate on what's known, not on how we know it.
Eubulides (talk) 19:09, 22 June 2009 (UTC)
Have we just confused early clinical trials with whether the reports about them are primary or secondary sources? Many Phase II trials are described in secondary sources. WhatamIdoing (talk) 20:33, 22 June 2009 (UTC)
Surely it's OK to cite a reliable review such as Fryer et al. 2009 (PMID 19442075) that discusses phase II trials, presumably along with other evidence. However, the original example given (Dhillon et al. 2008, PMID 18628464) is a primary source about a single phase II trial, and as I understand it the underlying dispute here is over whether it's OK to cite such sources. Eubulides (talk) 21:20, 22 June 2009 (UTC)
Even early and inconclusive trials can have major implications for the companies. If even a phase I/II trial is reported outside the scientific journals, we may need to cover it. The terms need to be used in individual articles. They're the exact descriptors, and people know them--they're now widely used in newspapers, all the patients lobbies know them, and so does the financial world. What would help is to add a short descriptor each time they are first used in a article (for safety) (for possible effectiveness) etc. That will be enough to orient the person who first comes across these terms in an article. Our articles should be in line with serious respected opinion, yes, but they also extend into areas where there is not yet defined medical opinion. If the article is written properly the status will be clear. (My basic rule is if it is well enough known that people will come to look for it in a general encyclopedia like this, it belongs here, which is approximately equivalent to the General notability guideline for things that the general or specialized newsmedia cover--such as new drugs. I would include the publications of the major patient lobbies as responsible media. DGG (talk) 04:45, 27 June 2009 (UTC)
I dunno, I just now searched Google News for "phase II clinical trial" and found that almost all news sources that used that phrase were press releases, stock tip sheets, and other similarly unreliable sources. Wikipedia medical articles are not the right place to pass along this kind of material. Sure, there are exceptions, truly notable phase II results that cry out to be mentioned even though no reliable reviews have been published yet; but these should be rare, and they should be removed in short order as reviews of these oh-so-notable results come in. Eubulides (talk) 05:19, 27 June 2009 (UTC)
I could imagine good reasons to mention a Phase II trial in an article about a biopharma company, and occasionally in an article about a drug, but I'm unconvinced that it should be mentioned in an article about a disease -- especially under "Treatment". WhatamIdoing (talk) 17:15, 27 June 2009 (UTC)

Absolutely. My main point was with regards to discussing treatments in clinical articles. I think we need to think really carefully about whether we go along with the mindless hype of newspapers to write hysterically about every in vitro study (in the UK, the Daily Mail is especially good at this) or try to educate by providing balanced high-quality context-driven content. JFW | T@lk 07:24, 28 June 2009 (UTC)

So perhaps a new section might be in order. What do you think of something like this:

Summarize relevant, currently accepted knowledge
Research is underway in nearly all areas of medicine. Although the results of a recent study might interest many people, from patients to investors, Wikipedia is not a newspaper and includes only encyclopedic information, in due proportion to its long-term importance. Medicine-related articles should present the current state of medical knowledge. Editors should normally not include speculative proposals and should avoid presenting early-stage research in ways that suggest it is widely accepted.
For example, the results of an early-stage clinical trial are unlikely to be appropriate for inclusion in the "Treatment" section of an article about a disease, because a possible future treatment has no bearing on current treatment practices. However, the results might, in some cases, be appropriate for inclusion in an article dedicated to the drug or treatment in question, or to the researchers or businesses involved in it. Such information might also be appropriate for a well-documented section on "Research directions" in an article about a disease. If including this information in this situation, it is frequently helpful to the reader to clearly identify the level of research (e.g., "first-in-human safety testing," "Phase II clinical trial") to prevent misunderstandings.

On the other hand: perhaps MEDRS is the wrong place for this. Perhaps instead it needs to be at WP:MEDMOS. WhatamIdoing (talk) 22:59, 28 June 2009 (UTC)

[edit] Assess evidence quality

Here is the first cut at a replacement for the Assess evidence quality section, for discussion. It's too long and wordy, but I thought I'd get it out the door now and we can trim it later. The basic idea is to incorporate some of the discussion mentioned above, and to trim away some of the unnecessary detail that's in the section now.

Several systems exist for assessing the quality of available evidence on medical subjects, and these should be kept in mind while assessing whether a particular viewpoint is a majority or minority one, and in deciding what constitutes evidence-based medicine.[1][2] The best evidence comes from meta-analyses of randomised controlled trials (RCTs), and from systematic reviews of bodies of literature of overall good quality and consistency addressing the specific recommendation. Narrative reviews can help establish the context of evidence quality. Roughly in descending order of quality, lower-quality evidence in medical research comes from individual RCTs, other controlled studies, quasi-experimental studies, and non-experimental studies such as comparative, correlation, and case control studies. Although expert committee reports or opinions, along with clinical experience of respected authorities, are weaker evidence than the scientific studies themselves, they often provide helpful overviews of evidence quality. Case reports, whether in the popular press or a peer-reviewed medical journal, are a form of anecdote and generally fall below the minimum requirements of reliable medical sources.

If an notable important scientific result is so new that no reliable reviews have been published on it, it may be helpful to cite the primary source that reported the result. Although popular-press news articles and press releases often tout the latest phase II clinical trial, such trials are rarely notable important enough to mention in an encyclopedia. Any such results should be described as being from a single study, for example:

"A 2009 U.S. study found the average age of formal autism spectrum diagnosis was 5.7 years." (citing PMID 19318992)

After enough time has passed for a review to be published in the area, the review should be cited in preference to the primary study. If no review is published in a reasonable amount of time, the primary source should be removed as not reporting an notable important result. When in doubt, omit mention of the primary study, as per WP:RECENTISM.

Speculative proposals and early-stage research should not be cited in ways that suggest wide acceptance. For example, the results of an early-stage clinical trial are unlikely to be appropriate for inclusion in the Treatment section of an article about a disease, because a possible future treatment has little bearing on current treatment practice. However, the results might, in some cases, be appropriate for inclusion in an article dedicated to the treatment in question, or to the researchers or businesses involved in it. Such information, particularly if citing a secondary source, might also be appropriate for a well-documented section on "Research directions" in an article about a disease. To prevent misunderstandings, the text should clearly identify the level of research cited, e.g., "first-in-human safety testing".

End of draft replacement. Eubulides (talk) 16:57, 2 July 2009 (UTC)

I've made a minor change to remove the word "notable". The use of this 'term of the art' on Wikipedia in contexts that relate to due weight issues instead of article inclusion criteria frequently leads to confusion. (I'm not committed to my word choice, just to the removal of the word "notable".) WhatamIdoing (talk) 17:38, 2 July 2009 (UTC)


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