The end of history?

A hundred years later the RCT may seem like the end of this history.1However, in critical care we are more aware than most that this would be a poor ending. Clinical trials have been notoriously fruitless in our field, and despite much promising pre-clinical work, this has been especially true in sepsis research.[Riedemann:2003] The main problem is that the delivery of a clinical trial is akin to measuring the meridian line. These are expensive juggernauts that can only ask one question at a time. Where the answer is subtle then the funds to power the trial machine will be exhausted before a small difference is detected.

There are new strategies that aim to make the clinical trial more agile2 However much we supercharge the randomised trial, it will never be able to keep pace with our need to understand the universe of clinical medicine. If big data is going to be the answer to this then it must show itself deserving of the trust that we place in an RCT. Google and friends are telling us that this will be machine learning and artificial intelligence. However if the diet of machine learning is big data, then we are likely to be disappointed. Methods which learn from data do not alone produce theory. Mendelian inheritance, the structure of the double helix, and the general theory of relativity were not problems with data waiting for machine learning to solve. Yes, it is possible that we could feed IBM’s Watson the position of the stars as documented by the ancients. Watson would likely do a good job of recognising that certain spots of light, the planets3, did not move in the same way as others. But to expect that from this Watson would suggest gravity, the Copernican universe, and Newton’s laws of motion is magical thinking.

  1. The End of History is a 1992 essay by Francis Fukuyama that argued that Western liberal democracy would be the final endpoint social and political development. A quarter of century later this claim seems rather premature. 

  2. This includes both platform trials, and now REMAP (Randomized Embedded Multifactorial Adaptive Platform). Here new treatment options are continuously added and removed, as they are discovered and assessed, and the randomisation is embedded in health care delivery. The EHR can even provide the realtime data collection and feedback loop.”Angus:2015jw” 

  3. from the Greek, wanderers, because their position relative to the other stars was not constant.