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Semmelweis Reflex: An Age-Old Prejudice
Journal Pre-proof Semmelweis Reflex: An Age-old Prejudice Dr Vipin Gupta, MS, MCh, Dr. Chhavi Saini, MBBS, Dr. Meher Oberoi, MBBS, Dr. Gagan Kalra, MBBS, Dr. Md Imran Nasir, MS PII:
S1878-8750(19)33040-2
DOI:
https://doi.org/10.1016/j.wneu.2019.12.012
Reference:
WNEU 13859
To appear in:
World Neurosurgery
Received Date: 21 August 2019 Revised Date:
2 December 2019
Accepted Date: 3 December 2019
Please cite this article as: Gupta V, Saini C, Oberoi M, Kalra G, Nasir MI, Semmelweis Reflex: An Ageold Prejudice, World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2019.12.012. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Semmelweis Reflex: An Age-old Prejudice
Dr.Vipin Gupta, MS, MCh 1 Dr. Chhavi Saini, MBBS 1 Dr. Meher Oberoi, MBBS 1 Dr. Gagan Kalra, MBBS 1 Dr. Md Imran Nasir, MS 1
1 Department of Neurosurgery, Government Medical College & Hospital, Chandigarh, India
Corresponding author: Dr.Vipin Gupta, MS, MCh Assistant Professor Department of Neurosurgery Government Medical College & Hospital, Chandigarh Email: [email protected] Tel No.: +91 9501071591
No Financial disclosures
Government Medical College and Hospital, Sector 32, Chandigarh, India
Semmelweis Reflex: An Age-old Prejudice
No Financial disclosures
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SEMMELWEIS REFLEX: An Age-old Prejudice ABSTRACT: Semmelweis reflex is a human behavioral tendency to stick to pre-existing beliefs and to reject fresh ideas that contradict them (despite adequate evidence). We aim to familiarize the readers with the term which not only has a significant historical background but also grave clinical implications. By means of review and analysis of literature on Semmelweis, the first section of our article briefs the story of Ignaz Semmelweis and brushes on the contributions of other intellectual researchers that were rebuffed initially. The discussion further explains the root cause of this dismissal, an inherent bias against uncertainty that may be at the core of our fear for new ideas. And finally, our article explores the means by which we can prevent ourselves from being a victim of rejection. KEYWORDS: Ignaz Semmelweis, Semmelweis reflex, Puerperal Fever, Idea Rejection. STRATEGIES USED: Only identified by searches of MEDLINE, Current Contents, PubMed and references from relevant articles. The search terms “Ignaz Semmelweis”, “Semmelweis Reflex”, “Belief Perseverance”, and “Article rejection” were used for this review. Abstracts and reports that were included were directly related to previously published work. INTRODUCTION: “All great truths begin as blasphemies.” Historically, almost every revolutionary idea has gone through three stages until acceptance: first being ridiculed, then opposed violently and then finally being accepted as self-evident. Be it Newton’s theory of Gravity or Einstein’s theory of Relativity; Sun being the center of Solar system or Theory of Continental drift; the Apple computer ;the smart phones that are ubiquitous in this day and age; the Mendelian laws of inheritance or Semmelweis’s concept of Hand Hygiene; all these ideas which are today considered as pillars of modern science were once brushed off as being absurd. The field of science is filled with such ideas, no matter how revolutionary, that often-faced years of irrational resistance before acceptance. This delay results in unnecessary losses that could have been prevented if legitimate discoveries were accepted and instituted in a timely manner once proven with evidence. In this article, we discuss this irrational tendency to reject new ideas despite adequate proof. As Ignaz Semmelweis’ story is a dynamic example of this phenomenon, we use his life to talk about this intriguing psychological phenomenon- “Semmelweis Reflex”.1,2 We talk about several other examples in the field of medicine and discuss methods with which we can protect ourselves from being a victim of this reflex. THE STORY OF IGNAZ SEMMELWEIS: Ignaz Phillip Semmelweis was a 19th century physician who pioneered hand hygiene as an antiseptic procedure in modern medicine. During his work at the Vienna General Hospital, he noticed that the first of the two clinics in the hospital had a mortality rate of 15·8% while mortality rate of the second clinic was a mere 7·6% in the year 1842.3This higher mortality was attributed to a disease called purpureal sepsis or child-bed fever, the understanding of which was poor at that time. [ILLUSTRATION 1: Yearly puerperal fever mortality rates for birth giving women at Vienna General Hospital’ maternity clinic for the period 1784-1848 reported by Semmelweis.4] Semmelweis, greatly bothered by the higher mortality in the first clinic, acutely observed contrasts between the first and second clinics’ procedures, atmosphere and even religious practices. A discernible distinction was that the first facility was controlled by medical students who performed autopsies while the second was run by midwives who did not.4In
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wake of a colleague acquiring a similar illness from an accidental stab with an autopsy knife, he postulated that the transfer of “cadaveric particles” from the autopsy room to pregnant women in the labor room caused contamination that prompted puerperal fever in the principal facility and subsequently, higher death rate.5 Acting swiftly on his observations, Semmelweis immediately instituted a hand washing protocol at his clinic which required all medical students to wash their hands with chlorinated lime before conducting any obstetrical examinations or deliveries. The mortality rate dropped dramatically from 12·2% in May 1847 to 2·2% in June, 1·2% in July and 1·9% in August.3 After his term at Vienna General Hospital ended, Semmelweis’s plea for extension was not granted and the concept of hand washing was not continually implemented following his departure from the obstetrical clinic in 1849.3 [ILLUSTRATION 2: Puerperal fever mortality rates for birth giving women at the first and second clinic at Vienna General Hospital 1833-1858 reported by Semmelweis.4] Given the wide spread indifference of his contemporaries he fell into severe depression and his public behavior turned inappropriate and unacceptable. Frustrated with his life and work in Vienna, Semmelweis moved to Budapest where he continued to propagate his practices by writing letters to prominent European Obstetricians, often, angrily worded and accusatory. To one of the professors he wrote: “Should you, Herr Hofrath, without having disproved my doctrine, continue to train your pupils [against it], I declare before God and the world that you are a murderer and the ‘History of Childbed Fever’ would not be unjust to you if it memorialized you as a medical Nero.”6 In 1865, Semmelweis was admitted to a mental asylum where he was beaten brutally with leather whips, put in a straitjacket and kept isolated in a dark cell where he died of septicemia. A gangrenous wound taking the life of this pioneer remains a sardonic event in the history of medical science. SEMMELWEIS REFLEX Semmelweis’s potentially life-saving doctrine was ignored, ridiculed and left unused despite strong data from the maternity clinic that even his strongest critics failed to provide any evidence against.1,3 With this kind of staggering proof, it is almost unimaginable that he would have faced any resistance at all, and yet, the medical community almost blatantly rejected the idea that hand hygiene could in fact, prevent puerperal sepsis. The disease had, at the time, claimed so many lives that just one simple intervention such as handwashing, despite its proven efficacy, appeared too simplistic a solution to this seemingly large problem.3,7 A lot of doctors took offence from the notion that they themselves were the conduits of this fatal infection.8 At the time, surgeons and specialists wore their blood-stained aprons as a trophy, a symbol of supreme knowledge and status. Asking them to clean their hands and aprons was to challenge their professional authority and social status. More over many clinicians in Vienna in the nineteenth century believed in ‘therapeutic nihilism’, claiming that the role of the physician was to assist nature.9 Many influential physicians and established doctors on chair held this belief, as William M. Johnston writes in The Austrian Mind: “By 1850, skepticism toward traditional therapy had so taken root that the only medicament used in the General Hospital was cherry brandy. For fear of distorting symptoms, doctors refused to prescribe any remedies.”10,11 There were several other factors that could have led the medical community to reject his hypothesis, but the predominant one remained a primal human behavioral tendency to stick to pre-existing beliefs and to reject fresh ideas that contradict these beliefs.3,7,12 This tendency is now often referred to as “Semmelweis Reflex”.1,2 WHY IS THIS STORY IMPORTANT?
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It took the advent of the germ theory by Louis Pasteur in the 1860s and Robert Koch’s postulates in 1890 to bring about an acceptance of what Ignaz Semmelweis had said all along. Decades later, hand washing is now considered common sense and forms the basis of prevention of infection in hospitals and at home. One can only wonder how many innocent lives would have been saved had this simple measure been accepted and instituted earlier. Semmelweis’ story serves as a reminder of two things. One, the practice of hand hygiene is nothing short of life saving in its own respect. It holds equal importance in clinical and paraclinical branches and is important as a protective measure not just for the patient but also for the physician as well. And second, that scientists, physicians and perhaps humanity, in general, must learn to introspect before arguing against a new idea. When questioning a hypothesis that discredits a prior belief, it is only ethical to confirm that our line of questioning is based on evidence and proof and that it is not merely a play of human tendency which needs to be overcome for progress to take place. IS THIS A COMMON PHENOMENON? Unfortunately, the history of medical science is replete with examples of path breaking ideas that endured years and sometimes even decades of rejection simply because they were ahead of their time. Some of them are briefly discussed. Leonardo da Vinci (1452-1519)13 He was an Italian polymath excelling in areas of painting, architecture, science, music, mathematics, anatomy, botany, history and so on. Historians and scholars regard him as the prime exemplar of Universal genius, an individual with ‘feverishly inventive imagination’. He began his anatomical studies in 1506. His works include detailed illustrations of skull, heart, muscle and vessels.14 He performed autopsies and was the first to describe atherosclerosis and cirrhosis. He also discovered that the heart and not the liver were at the core of blood supply. He even described coronary sinus and flow of blood long before Valsalva or Harvey, respectively. During those days dissection of animals and humans was frowned upon. After returning to Rome, he was accused of witchcraft. His work was written in mirrored left hand and it went unrecognized and unpublished.15 William Harvey (1578-1657)16 An English physician from the 17th century, who unraveled the mystery of human circulatory system, had his fair share of struggle trying to afloat his knowledge through his book. Galen and his theory that it is the liver that pumps blood throughout the body was much prevalent in the scientific community at the time and hence many physicians chose to sail with Galen than to side with Harvey’s truth.17 Harvey later articulated how hard it had been for him as he claimed that one’s better off growing wise in private than to be a public stir. It was only years later that his work gained the much-deserved credit. Franz Joseph Gall (1758 –1828) The German neuroanatomist, Franz Joseph Gall, and his concept of brain localization met with skepticism from other scientists at the time.18,19 Even religious and monarchial contemporaries found his concepts to be unacceptable.18 It was only many years later, that his work got widespread attention in England. His contributions to the field of phrenology have proven quintessential over the years. Sir Gregor Johann Mendel (1822-84)20 In 1866, Mendel came up with the laws of constant elements for a great but finite variation which was in total contrast to Darwin’s theory that acquired characters are inherited and the process of evolution is continuous.21 These radical theories and hypothesis coming from a monk who was experimenting on peas and flowers were seen as rather foolish.22Darwin’s theory was well accepted at the time and Mendel’s ideas were totally opposite to the prevalent belief,
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so it was only years after his death he got credit for his path breaking discovery. He is now considered as the ‘Father of Modern Genetics’ and the laws he gave are known as ‘Mendelian laws of Inheritance’.23 Louis Pasteur (1822-1895)24 The very foundation of modern medicine and infectious disease is based on the work of Louis Pasteur, a French chemist and microbiologist. His theory that it was germs that spread disease met with elaborate resistance from the scientific community as theory of spontaneous generation was prevalent at the time. 25His contributions later, enabled scientists like Lister and Fleming to make revolutionary and indispensable strides in medicine. Stephane Tarnier (1828-97) It is almost impossible to imagine a Neonatal Intensive Care Unit without an incubator today. First pioneered by French obstetrician Stephane Tarnier, infant incubators26 were initially used and refined throughout Europe in the late nineteenth century. Having realized that a constant temperature was not the only essential factor for infant survival, he considered other aspects like hygiene, isolation, appropriate adequate feeding, and a humid but warm environment. The inspiration had come from a device being used to incubate poultry and during his time at Paris Maternite (1881), he introduced devices that were box like compartments made out of wood and covered with glass lids with hot water bottles inside. He was calling them - “Baby warming device” a “couveuse” and these helped reduce infant mortality by 28% over three years at Paris Maternite. 26 But when these machines were first introduced in the USA, they were widely disregarded, rather mocked upon. In order to familiarize the common US public with incubators and their importance in saving lives, Tarnier’s associate Couney began a side show at Coney Island, New York where viewers would pay 25 cents to look at tiny babies. This money was used to keep the treatment going for those babies.27 Peyton Francis Rous (1879-1970) Dr. Rous was an American virologist known for his research on Oncoviruses. In 1910, he observed that exposure to a cell-free filtrate could lead to transference of a malignant tumor (specifically, a sarcoma) growing on a domestic chicken to another fowl.28 At the time, his findings proving a virus could in-fact be the transmitting agent for cancer, were not very well accepted as most of the field experts held the view that malignancy was not infectious and favored clarifications which found the origin of cancer in the internal system of the cell.29 His ideas were later embraced by the scientific fraternity and was awarded the Nobel Prize, 40 years later in 1966.30,31 Stanley B. Pruisner Stanley Benjamin Pruisner is an American Neurologist and is the director of the Institute for Neurodegenerative Diseases at the University of California, San Francisco.32For many years scientists believed that only bacteria, virus and fungi could cause diseases as they possess genetic material. Pruisner discovered that prions (protein particles) could also cause diseases. He faced unanimous opposition for the fact that protein had no genetic material of their own. Despite Prusiner's bold attempts to prove the protein-only hypothesis, years passed before it was generally accepted by most of the scientific community.33 Today, we know that mad cow disease and Creutzfeldt-Jakob disease are caused by prions. He won the Nobel Prize in 1997.34-36 Bennet Omalu Dr. Omalu is a Nigerian American physician, forensic pathologist and neuropathologist.37With ongoing studies he discovered a common finding in most of his cases which was chronic traumatic encephalopathy (CTE).38He started publishing his findings when he was widely opposed by one of the biggest organizations in the country, the National Football League (NFL).39Not only massive amount of funds but also a game so dear to the crowd was at stake. Allegedly one of the NFL doctors reportedly asked Dr. Omalu. "If 10 percent of mothers in this country would begin to
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perceive football as a dangerous sport that is the end of football."40Dozens of players are now diagnosed with CTE which serves as evidence to Omalu’s theory.41,42 Harold Ridley The British Inventor faced strong opposition when he presented his paper on the first Intra Ocular Lens(IOL) implantation. His contemporaries at the time refused to acknowledge his work despite conclusive evidence supporting his claims.43,44 It was only after 30 years of his first successful IOL implant, that his peers began to grant him the recognition he deserved. His pioneering work with the IOLs and cataract surgery forms the basis of the most commonly performed ophthalmic surgery till date. Andreas Roland Gruntzig Dr. Gruntzig (a German Cardiologist) was cynically received when he first pitched the idea of balloon angioplasty in the American Heart Association annual meet. Dr King, a renowned catheterization specialist at the time said dismissively, “It’ll never work.”45 Dr. Gruntzig, however was persistent on his idea and despite everyone telling him that his idea was going to fail, he remained undeterred. It was only a year later in 1977, when he presented his first four angioplasty cases in humans, that the entire audience in the meet rose to applaud his work. Robin Warren and Dr. Barry Marshall Dr. Warren (Pathologist) and Dr. Marshall (Microbiologist) are both Nobel laureates from Australia who found out that stomach ulcers were caused by bacteria.46Even by 1980s, medical community was stagnant in their beliefs regarding the etiology of stomach ulcers. Years of experience and knowledge led them to believe that stomach ulcers were caused by stress or spicy food.47To some, the idea that the ulcers were caused by a bacterium was absurd. While the other doctors in the medical community argued that no bacteria could live in the acidic environment of the stomach. To prove himself right Barry ingested the bacterial culture and developed ulcers himself.48He then took the antibiotics and got cured. Marshall and Warren won a Nobel Prize in 2005 for their discovery.49 They also developed the 14-C Urea Breath Test for detection of Helicobacter pylori in patients with peptic ulcer disease.46 Jeremy Griffith His work on the “Human Condition” and his theory that teleology is the underlying order in nature, met with criticism from prevalent journals at the time.50 Now, however, teleology is being increasingly accepted. With many federal and private multi-million-dollar initiatives now in place, the area is a prospect in the domain of psychology in the current day. James Allison The Nobel laureate was initially met with skeptic denials when he presented his idea targeting the immune system in cancer management. At that time, immune system was not considered a major role player in cancer and because of which his novel idea and pioneering research could not catch immediate attention of the scientific community. Now, however, drugs based on his initial ideas are set to become the most successful cancer drugs on the market.51 Dr Allison’s work was recognized and he received a Nobel Prize for his contributions in 2018. HOW CAN WE PROTECT OURSELVES FROM SEMMELWEIS REFLEX? Evidence suggests that 21% of papers are rejected without review and approximately 40% are rejected after peer review according to American Journal Experts. This data suggests that around 1/4th of the articles are dismissed and the reason for the dismissal is either the research itself or the writing and presentation of the paper.52,53 In this extract we are focusing on the former. If your research is being refuted for merely the content or ideologies, then you may have become a victim of ‘Semmelweis reflex’. The theory that explains this bias, stems from the tendency to hold on to one’s
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initial belief even after receiving new information that contradicts or disconfirms the basis of that belief. This phenomenon is known as Belief Perseverance.54 Correlation and Causation: The theory of illusionary correlation here comes into play. This is phenomenon of perceiving a relationship between variables even when no such relationship exists e.g. in case of Semmelweis’s opposition, a part of the argument was that doctors were considered to be knowledgeable and respected.55 Medical fraternity simply refused to believe that they could in fact spread infection when in reality there is no correlation between professional stature and sterility or asepsis. Another example would be that of a perceived relationship between skin color or nationality or origin and professional competence which may have been a contributory factor in the opposition faced by African immigrant Dr. Bennet Omalu.56By means of this article we would also like to further this so that experts today are not blind to the blatant similarities between themselves and 16th century scholars who wouldn’t look through Galileo’s telescope and 19th century doctors who refused to wash their hands. Another way to look at this is a common mistake on the parts of researchers to assume that just because we find a correlation between two variables, one causes the other. This is often described in statistical parlance as “Correlation does not imply causation”.57 Clear Impact: When the editor of a journal starts reading the submitted article, they look for a message to be delivered. Always make sure that while writing the article, you must not sway from the reason the study was done and what impact it has on the present-day understanding. Also, one must clearly state the reason for the study in the abstract only so as when people read it further, they should reason along with. The text should not be ambiguous making the reader decipher it in their own understanding. Critically analyze your study yourself: Critically evaluate your own study and findings. Know the implications of what you are hypothesizing. Keep in mind the age-old beliefs and also established ethical standards. Make sure that if you are going against a proven and widely accepted theory, you do so not in a very exclusive fashion, rather give some credibility to it. Although it is indeed true that there is no easy, non-threatening, safe way to contradict established norms especially when they are based on fears, prejudices and self-serving deceptions. Hence be bold enough to come up with your statement. Critically analyze your own study and findings. Talk to people with opposing views and try to answer their questions. Another method is to imagine or explain how the opposite belief might be true. This de-biasing technique is known as counter explanation. It will help you to make sound conclusions rather than jumping to assumptions. Personal involvement: Be personally involved in the process. It is often argued that Semmelweis’s hypothesis was poorly understood by the medical community at that time because he did not personally publish his data until much after his dismissal from Vienna General Hospital.58 Most of the information on his studies came from his colleagues and students.59 Journal Selection: Sandesh and Wahrekar concluded of the 24 factors considered for journal selection, the most important ones being Journal indexing, online submission, impact factor, peer review and publication fees.60 Once the study is complete and the manuscript is ready, it should be submitted in a journal which relates with the article. Authors should pay careful attention to the contributions that their manuscript is making to the pre-existing literature. A broader content matter may be considered relevant for journals that cater to such audiences and vice versa. As Carroll-Johnson (2001) noted, “Choosing the wrong journal can result in outright rejection or, worse, rejection only after a lengthy peer review process that reveals the paper is just not suitable.”61 Another important consideration in journal selection is the impact factor of the journal. One should not get tempted to submit a manuscript in a journal with high impact factor but
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should also see the suitability of the research for the journal.62 Impact factor depends on the number of readers associated with the journal. However, a journal with high readership would likely only accept practice-changing research that would impact a broader audience. With a carefully thought out study design and rigorous quality control measures in place, a high-quality manuscript may be considered for submission to a relevant journal with high readership. Social Media as an outlet: Sometimes you may also face what is known as a publication bias in which the journal authorities may have some subjective reasons to refuse your paper. Whatever may be the reason, in this era of artificial intelligence and cloud computing other means like Social Media and Mass Media are rapid ways to get the word out to the common man. More importantly future research would benefit from cross-media, cross-time and cross-country comparisons on the use of media in social movements.63 Knowing your Limitations: Above all, the tale of Ignaz Semmelweis shows us the significance of having faith in your discovery and standing by it despite resistance. It is easy to become arrogant when you feel like you know more than your peers but understand that your knowledge can’t do much good until it is understood, accepted and instituted widely. Often the road to triumph and acceptance is a long and gruesome one; as the great physicist Stephan Hawking quotes in his proclaimed book, A Brief History of Time: “A scientific truth doesn’t triumph by convincing its opponents and making them see the light but rather because its opponents eventually die and a new generation grows up that is familiar with it.” 64 Exercising caution: Although scientific work that is rejected only to be later accepted needs careful assortment, it is of utmost importance that authenticity and credibility of this work be validated through rigorous review and discussion. Semmelweis reflex does cause delays in acceptance of relevant scientific result, but it also protects us from accepting apparently impactful work that may not be of public good. Certain examples of research works that were initially though to be impactful and practice changing only to be later found that those claims were misplaced are: recombinant factor VIIa, pancreatic resections for nesidioblastosis, anal fistula management by using fistula plugs and extracranial to intracranial bypass arterial anastomosis to reduce stroke. 65 Frontal lobotomy for medicine-refractory-schizophrenia and thalidomide are examples of research works that were later found to be harmful instead.66,67 Summary: Semmelweis reflex is, in fact, an age-old prejudice. It is an inherent human tendency and there is no paucity of historic anecdotes that embody this phenomenon. We have highlighted key elements that prove monumental in the realization of true potential of a new idea, while still exercising necessary caution. With careful and thorough analysis of available literature, we have identified certain steps that when instituted may help in protecting oneself from being a victim of this reflex. A patient, calm, innovative yet intuitive approach is required to make it through the initial friction that any new idea has to face. Perseverance in exercising scientific rigor and meticulous study design are quintessential for an idea to reach fruition. Exercising utmost caution with perception, interpretation, critical self-analysis, the choice of journal and knowing one’s own limitations are few of the many highlighted cornerstones in this review. Science is a sanctum of innovation and discovery. For any new thought, there emerge numerous unanswered questions, many of them being critical and rightfully so, but it is the scientist who must never lose sight of the direction of that original thought, as it may just be the next big leap in science that changes the fate of humanity.
No conflict of interests
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26. Dunn PM. Stéphane Tarnier (1828–1897), the architect of perinatology in France. Archives of Disease in Childhood-Fetal and Neonatal Edition 2002; 86(2): F137-F9. 27. Proctor K. Transferring the Incubator: Fairs and Freak-Shows as Agents of Change. Economics 1995; 19: 5-24. 28. Van Epps HL. Peyton Rous: father of the tumor virus. The Journal of experimental medicine 2005; 201(3): 320. 29. Becsei-Kilborn E. Scientific discovery and scientific reputation: the reception of Peyton Rous’ discovery of the chicken sarcoma virus. Journal of the History of Biology 2010; 43(1): 111-57. 30. Rous P. A sarcoma of the fowl transmissible by an agent separable from the tumor cells. The Journal of experimental medicine 1911; 13(4): 397. 31. Rous P. A transmissible avian neoplasm.(sarcoma of the common fowl.). Journal of Experimental Medicine 1910; 12(5): 696-705. 32. Available from: http://profiles.ucsf.edu/stanley.prusiner. (accessed 29 June 2019). 33. Zabel MD, Reid C. A brief history of prions. Pathogens and disease 2015; 73(9). 34. Prusiner SB. Novel proteinaceous infectious particles cause scrapie. Science 1982; 216(4542): 136-44. 35. Prusiner SB. Molecular biology of prion diseases. Science 1991; 252(5012): 1515-22. 36. Available from: https://www.nobelprize.org/prizes/medicine/1997/prusiner/biographical/. (accessed 29 June 2019). 37. Available from: https://www.wsj.com/articles/the-doctor-the-nfl-tried-to-silence-1448399061. (accessed 29 June 2019). 38. Omalu B. Chronic traumatic encephalopathy. Concussion: Karger Publishers; 2014: 38-49. 39. Available from: https://www.nytimes.com/2013/08/24/sports/football/nfl-pressure-said-to-prompt-espnto-quit-film-project.html. (accessed 29 June 2019). 40. Available from: https://www.cbssports.com/nfl/news/frontline-pbs-doc-league-of-denial-examines-nflconcussion-problem/. (accessed 29 June 2019). 41. Omalu BI, DeKosky ST, Minster RL, Kamboh MI, Hamilton RL, Wecht CH. Chronic traumatic encephalopathy in a National Football League player. Neurosurgery 2005; 57(1): 128-34. 42. Available from: http://discovermagazine.com/2016/jul-aug/ahead-of-the-hit. (accessed 29 June 2019). 43. Apple DJ, Sims J. Harold Ridley and the invention of the intraocular lens. Survey of ophthalmology 1996; 40(4): 279-92. 44. Vail D. Discussion of Ridley H: Further observations on intraocular acrylic lenses. Trans Am Acad Ophthalmol Otolaryngol 1953; 57(104): 99. 45. Forrester J. The Heart Healers: The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives: Macmillan; 2015. 46. Marshall B, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. The Lancet 1984; 323(8390): 1311-5. 47. Ahmed N. 23 years of the discovery of Helicobacter pylori: Is the debate over? : BioMed Central; 2005. 48. Marshall BJ, Armstrong JA, McGechie DB, Clancy RJ. Attempt to fulfil Koch's postulates for pyloric Campylobacter. Medical Journal of Australia 1985; 142(8): 436-9. 49. Available from: https://www.nobelprize.org/prizes/medicine/2005/summary/. (accessed 29 June 2019). 50. Available from: https://www.humancondition.com/jeremy-griffith/. (accessed 29 June 2019). 51. Available from: https://www.forbes.com/sites/simonking/2015/06/01/the-biggest-selling-cancer-drugs-in2020-significant-change-expected-in-five-short-years/#502f375d151d. (accessed 29 June 2019). 52. Bowler S. COMMON REASONS WHY ACADEMIC PAPERS ARE REJECTED BY JOURNAL EDITORS. 53. Available from: https://www.elsevier.com/connect/8-reasons-i-rejected-your-article. (accessed 29 June 2019). 54. Anderson CA. Belief perseverance. Encyclopedia of social psychology 2007: 109-10. 55. Pelham B, Blanton H. Conducting research in psychology: Measuring the weight of smoke: Nelson Education; 2012. 56. Hamilton DL, Gifford RK. Illusory correlation in interpersonal perception: A cognitive basis of stereotypic judgments. Journal of Experimental Social Psychology 1976; 12(4): 392-407. 57. Aldrich J. Correlations genuine and spurious in Pearson and Yule. Statistical science 1995; 10(4): 364-76. 58. Nuland SB. The doctors' plague: germs, childbed fever, and the strange story of Ignac Semmelweis (great discoveries): WW Norton & Company; 2004. 59. Reid R. Microbes and men. 1974. 60. Sandesh N, Wahrekar S. Choosing the scientific journal for publishing research work: perceptions of medical and dental researchers. Clujul Medical 2017; 90(2): 196. 61. Carroll-Johnson RM. Submitting a Manuscript for Review. Clinical Journal of Oncology Nursing 2001; 5.
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62. Available from: https://www.aje.com/en/arc/choosing-right-journal-your-research/. (accessed 29 June 2019). 63. Della Porta D, Mattoni A. Social Movements. The International Encyclopedia of Political Communication 2015: 1-8. 64. Planck M. Scientific autobiography: And other papers: Open Road Media; 2014. 65. Ball CG, Grondin SC, Pasieka JL, et al. Examples of dramatic failures and their effectiveness in modern surgical disciplines: can we learn from our mistakes? Journal of Comparative Effectiveness Research 2018; 7(7): 70920. 66. Faria Jr MA. Violence, mental illness, and the brain–A brief history of psychosurgery: Part 1–From trephination to lobotomy. Surgical neurology international 2013; 4. 67. Dally A. Thalidomide: was the tragedy preventable? The Lancet 1998; 351(9110): 1197-9.
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[ILLUSTRATION 1: Yearly puerperal fever mortality rates for birth giving women at Vienna General Hospital’ maternity clinic for the period 1784-1848 reported by Semmelweis.2]
13.000%
11.375%
9.750%
8.125%
6.500%
4.875%
3.250%
1.625%
0.000% 1784
1788
1792
1796
1800
1804
1808
1812
1816
1820
1824
1828
1832
1836
1840
1844
1848
Hand-washing introduced
20%
First Clinic Second Clinic
15%
10%
5%
0% 1833 1835 1837 1839 1841 1843 1845 1847 1849 1851 1853 1855 1857 Hand-washing introduced [ILLUSTRATION 2: Puerperal fever mortality rates for birth giving women at the first and second clinic at Vienna General Hospital 1833-1858 reported by Semmelweis.2]
Dr Vipin K Gupta: Conceptualization, Methodology, Data curation, Resources, writing original draft, Writing-review and editing, visualization, supervision, Project administration Dr Chhavi Saini: Conceptualization, Methodology, Data curation, Resources, writing original draft, Writing-review and editing, visualization Dr Gagan Kalra: Conceptualization, Methodology, Data curation, Resources, writing original draft, Writing-review and editing, visualization Dr Meher Oberoi: Conceptualization, methodology, Data curation, Resources, Writing original draft Dr Md I Nasir: Data curation, Resources, writing original draft, writing-review and editing, visualization Dr Soumya Gupta: Resources, writing original draft, writing review and editing, visualization
No abbreviations were used.
S1878-8750(19)33040-2
DOI:
https://doi.org/10.1016/j.wneu.2019.12.012
Reference:
WNEU 13859
To appear in:
World Neurosurgery
Received Date: 21 August 2019 Revised Date:
2 December 2019
Accepted Date: 3 December 2019
Please cite this article as: Gupta V, Saini C, Oberoi M, Kalra G, Nasir MI, Semmelweis Reflex: An Ageold Prejudice, World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2019.12.012. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
Semmelweis Reflex: An Age-old Prejudice
Dr.Vipin Gupta, MS, MCh 1 Dr. Chhavi Saini, MBBS 1 Dr. Meher Oberoi, MBBS 1 Dr. Gagan Kalra, MBBS 1 Dr. Md Imran Nasir, MS 1
1 Department of Neurosurgery, Government Medical College & Hospital, Chandigarh, India
Corresponding author: Dr.Vipin Gupta, MS, MCh Assistant Professor Department of Neurosurgery Government Medical College & Hospital, Chandigarh Email: [email protected] Tel No.: +91 9501071591
No Financial disclosures
Government Medical College and Hospital, Sector 32, Chandigarh, India
Semmelweis Reflex: An Age-old Prejudice
No Financial disclosures
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SEMMELWEIS REFLEX: An Age-old Prejudice ABSTRACT: Semmelweis reflex is a human behavioral tendency to stick to pre-existing beliefs and to reject fresh ideas that contradict them (despite adequate evidence). We aim to familiarize the readers with the term which not only has a significant historical background but also grave clinical implications. By means of review and analysis of literature on Semmelweis, the first section of our article briefs the story of Ignaz Semmelweis and brushes on the contributions of other intellectual researchers that were rebuffed initially. The discussion further explains the root cause of this dismissal, an inherent bias against uncertainty that may be at the core of our fear for new ideas. And finally, our article explores the means by which we can prevent ourselves from being a victim of rejection. KEYWORDS: Ignaz Semmelweis, Semmelweis reflex, Puerperal Fever, Idea Rejection. STRATEGIES USED: Only identified by searches of MEDLINE, Current Contents, PubMed and references from relevant articles. The search terms “Ignaz Semmelweis”, “Semmelweis Reflex”, “Belief Perseverance”, and “Article rejection” were used for this review. Abstracts and reports that were included were directly related to previously published work. INTRODUCTION: “All great truths begin as blasphemies.” Historically, almost every revolutionary idea has gone through three stages until acceptance: first being ridiculed, then opposed violently and then finally being accepted as self-evident. Be it Newton’s theory of Gravity or Einstein’s theory of Relativity; Sun being the center of Solar system or Theory of Continental drift; the Apple computer ;the smart phones that are ubiquitous in this day and age; the Mendelian laws of inheritance or Semmelweis’s concept of Hand Hygiene; all these ideas which are today considered as pillars of modern science were once brushed off as being absurd. The field of science is filled with such ideas, no matter how revolutionary, that often-faced years of irrational resistance before acceptance. This delay results in unnecessary losses that could have been prevented if legitimate discoveries were accepted and instituted in a timely manner once proven with evidence. In this article, we discuss this irrational tendency to reject new ideas despite adequate proof. As Ignaz Semmelweis’ story is a dynamic example of this phenomenon, we use his life to talk about this intriguing psychological phenomenon- “Semmelweis Reflex”.1,2 We talk about several other examples in the field of medicine and discuss methods with which we can protect ourselves from being a victim of this reflex. THE STORY OF IGNAZ SEMMELWEIS: Ignaz Phillip Semmelweis was a 19th century physician who pioneered hand hygiene as an antiseptic procedure in modern medicine. During his work at the Vienna General Hospital, he noticed that the first of the two clinics in the hospital had a mortality rate of 15·8% while mortality rate of the second clinic was a mere 7·6% in the year 1842.3This higher mortality was attributed to a disease called purpureal sepsis or child-bed fever, the understanding of which was poor at that time. [ILLUSTRATION 1: Yearly puerperal fever mortality rates for birth giving women at Vienna General Hospital’ maternity clinic for the period 1784-1848 reported by Semmelweis.4] Semmelweis, greatly bothered by the higher mortality in the first clinic, acutely observed contrasts between the first and second clinics’ procedures, atmosphere and even religious practices. A discernible distinction was that the first facility was controlled by medical students who performed autopsies while the second was run by midwives who did not.4In
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wake of a colleague acquiring a similar illness from an accidental stab with an autopsy knife, he postulated that the transfer of “cadaveric particles” from the autopsy room to pregnant women in the labor room caused contamination that prompted puerperal fever in the principal facility and subsequently, higher death rate.5 Acting swiftly on his observations, Semmelweis immediately instituted a hand washing protocol at his clinic which required all medical students to wash their hands with chlorinated lime before conducting any obstetrical examinations or deliveries. The mortality rate dropped dramatically from 12·2% in May 1847 to 2·2% in June, 1·2% in July and 1·9% in August.3 After his term at Vienna General Hospital ended, Semmelweis’s plea for extension was not granted and the concept of hand washing was not continually implemented following his departure from the obstetrical clinic in 1849.3 [ILLUSTRATION 2: Puerperal fever mortality rates for birth giving women at the first and second clinic at Vienna General Hospital 1833-1858 reported by Semmelweis.4] Given the wide spread indifference of his contemporaries he fell into severe depression and his public behavior turned inappropriate and unacceptable. Frustrated with his life and work in Vienna, Semmelweis moved to Budapest where he continued to propagate his practices by writing letters to prominent European Obstetricians, often, angrily worded and accusatory. To one of the professors he wrote: “Should you, Herr Hofrath, without having disproved my doctrine, continue to train your pupils [against it], I declare before God and the world that you are a murderer and the ‘History of Childbed Fever’ would not be unjust to you if it memorialized you as a medical Nero.”6 In 1865, Semmelweis was admitted to a mental asylum where he was beaten brutally with leather whips, put in a straitjacket and kept isolated in a dark cell where he died of septicemia. A gangrenous wound taking the life of this pioneer remains a sardonic event in the history of medical science. SEMMELWEIS REFLEX Semmelweis’s potentially life-saving doctrine was ignored, ridiculed and left unused despite strong data from the maternity clinic that even his strongest critics failed to provide any evidence against.1,3 With this kind of staggering proof, it is almost unimaginable that he would have faced any resistance at all, and yet, the medical community almost blatantly rejected the idea that hand hygiene could in fact, prevent puerperal sepsis. The disease had, at the time, claimed so many lives that just one simple intervention such as handwashing, despite its proven efficacy, appeared too simplistic a solution to this seemingly large problem.3,7 A lot of doctors took offence from the notion that they themselves were the conduits of this fatal infection.8 At the time, surgeons and specialists wore their blood-stained aprons as a trophy, a symbol of supreme knowledge and status. Asking them to clean their hands and aprons was to challenge their professional authority and social status. More over many clinicians in Vienna in the nineteenth century believed in ‘therapeutic nihilism’, claiming that the role of the physician was to assist nature.9 Many influential physicians and established doctors on chair held this belief, as William M. Johnston writes in The Austrian Mind: “By 1850, skepticism toward traditional therapy had so taken root that the only medicament used in the General Hospital was cherry brandy. For fear of distorting symptoms, doctors refused to prescribe any remedies.”10,11 There were several other factors that could have led the medical community to reject his hypothesis, but the predominant one remained a primal human behavioral tendency to stick to pre-existing beliefs and to reject fresh ideas that contradict these beliefs.3,7,12 This tendency is now often referred to as “Semmelweis Reflex”.1,2 WHY IS THIS STORY IMPORTANT?
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It took the advent of the germ theory by Louis Pasteur in the 1860s and Robert Koch’s postulates in 1890 to bring about an acceptance of what Ignaz Semmelweis had said all along. Decades later, hand washing is now considered common sense and forms the basis of prevention of infection in hospitals and at home. One can only wonder how many innocent lives would have been saved had this simple measure been accepted and instituted earlier. Semmelweis’ story serves as a reminder of two things. One, the practice of hand hygiene is nothing short of life saving in its own respect. It holds equal importance in clinical and paraclinical branches and is important as a protective measure not just for the patient but also for the physician as well. And second, that scientists, physicians and perhaps humanity, in general, must learn to introspect before arguing against a new idea. When questioning a hypothesis that discredits a prior belief, it is only ethical to confirm that our line of questioning is based on evidence and proof and that it is not merely a play of human tendency which needs to be overcome for progress to take place. IS THIS A COMMON PHENOMENON? Unfortunately, the history of medical science is replete with examples of path breaking ideas that endured years and sometimes even decades of rejection simply because they were ahead of their time. Some of them are briefly discussed. Leonardo da Vinci (1452-1519)13 He was an Italian polymath excelling in areas of painting, architecture, science, music, mathematics, anatomy, botany, history and so on. Historians and scholars regard him as the prime exemplar of Universal genius, an individual with ‘feverishly inventive imagination’. He began his anatomical studies in 1506. His works include detailed illustrations of skull, heart, muscle and vessels.14 He performed autopsies and was the first to describe atherosclerosis and cirrhosis. He also discovered that the heart and not the liver were at the core of blood supply. He even described coronary sinus and flow of blood long before Valsalva or Harvey, respectively. During those days dissection of animals and humans was frowned upon. After returning to Rome, he was accused of witchcraft. His work was written in mirrored left hand and it went unrecognized and unpublished.15 William Harvey (1578-1657)16 An English physician from the 17th century, who unraveled the mystery of human circulatory system, had his fair share of struggle trying to afloat his knowledge through his book. Galen and his theory that it is the liver that pumps blood throughout the body was much prevalent in the scientific community at the time and hence many physicians chose to sail with Galen than to side with Harvey’s truth.17 Harvey later articulated how hard it had been for him as he claimed that one’s better off growing wise in private than to be a public stir. It was only years later that his work gained the much-deserved credit. Franz Joseph Gall (1758 –1828) The German neuroanatomist, Franz Joseph Gall, and his concept of brain localization met with skepticism from other scientists at the time.18,19 Even religious and monarchial contemporaries found his concepts to be unacceptable.18 It was only many years later, that his work got widespread attention in England. His contributions to the field of phrenology have proven quintessential over the years. Sir Gregor Johann Mendel (1822-84)20 In 1866, Mendel came up with the laws of constant elements for a great but finite variation which was in total contrast to Darwin’s theory that acquired characters are inherited and the process of evolution is continuous.21 These radical theories and hypothesis coming from a monk who was experimenting on peas and flowers were seen as rather foolish.22Darwin’s theory was well accepted at the time and Mendel’s ideas were totally opposite to the prevalent belief,
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so it was only years after his death he got credit for his path breaking discovery. He is now considered as the ‘Father of Modern Genetics’ and the laws he gave are known as ‘Mendelian laws of Inheritance’.23 Louis Pasteur (1822-1895)24 The very foundation of modern medicine and infectious disease is based on the work of Louis Pasteur, a French chemist and microbiologist. His theory that it was germs that spread disease met with elaborate resistance from the scientific community as theory of spontaneous generation was prevalent at the time. 25His contributions later, enabled scientists like Lister and Fleming to make revolutionary and indispensable strides in medicine. Stephane Tarnier (1828-97) It is almost impossible to imagine a Neonatal Intensive Care Unit without an incubator today. First pioneered by French obstetrician Stephane Tarnier, infant incubators26 were initially used and refined throughout Europe in the late nineteenth century. Having realized that a constant temperature was not the only essential factor for infant survival, he considered other aspects like hygiene, isolation, appropriate adequate feeding, and a humid but warm environment. The inspiration had come from a device being used to incubate poultry and during his time at Paris Maternite (1881), he introduced devices that were box like compartments made out of wood and covered with glass lids with hot water bottles inside. He was calling them - “Baby warming device” a “couveuse” and these helped reduce infant mortality by 28% over three years at Paris Maternite. 26 But when these machines were first introduced in the USA, they were widely disregarded, rather mocked upon. In order to familiarize the common US public with incubators and their importance in saving lives, Tarnier’s associate Couney began a side show at Coney Island, New York where viewers would pay 25 cents to look at tiny babies. This money was used to keep the treatment going for those babies.27 Peyton Francis Rous (1879-1970) Dr. Rous was an American virologist known for his research on Oncoviruses. In 1910, he observed that exposure to a cell-free filtrate could lead to transference of a malignant tumor (specifically, a sarcoma) growing on a domestic chicken to another fowl.28 At the time, his findings proving a virus could in-fact be the transmitting agent for cancer, were not very well accepted as most of the field experts held the view that malignancy was not infectious and favored clarifications which found the origin of cancer in the internal system of the cell.29 His ideas were later embraced by the scientific fraternity and was awarded the Nobel Prize, 40 years later in 1966.30,31 Stanley B. Pruisner Stanley Benjamin Pruisner is an American Neurologist and is the director of the Institute for Neurodegenerative Diseases at the University of California, San Francisco.32For many years scientists believed that only bacteria, virus and fungi could cause diseases as they possess genetic material. Pruisner discovered that prions (protein particles) could also cause diseases. He faced unanimous opposition for the fact that protein had no genetic material of their own. Despite Prusiner's bold attempts to prove the protein-only hypothesis, years passed before it was generally accepted by most of the scientific community.33 Today, we know that mad cow disease and Creutzfeldt-Jakob disease are caused by prions. He won the Nobel Prize in 1997.34-36 Bennet Omalu Dr. Omalu is a Nigerian American physician, forensic pathologist and neuropathologist.37With ongoing studies he discovered a common finding in most of his cases which was chronic traumatic encephalopathy (CTE).38He started publishing his findings when he was widely opposed by one of the biggest organizations in the country, the National Football League (NFL).39Not only massive amount of funds but also a game so dear to the crowd was at stake. Allegedly one of the NFL doctors reportedly asked Dr. Omalu. "If 10 percent of mothers in this country would begin to
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perceive football as a dangerous sport that is the end of football."40Dozens of players are now diagnosed with CTE which serves as evidence to Omalu’s theory.41,42 Harold Ridley The British Inventor faced strong opposition when he presented his paper on the first Intra Ocular Lens(IOL) implantation. His contemporaries at the time refused to acknowledge his work despite conclusive evidence supporting his claims.43,44 It was only after 30 years of his first successful IOL implant, that his peers began to grant him the recognition he deserved. His pioneering work with the IOLs and cataract surgery forms the basis of the most commonly performed ophthalmic surgery till date. Andreas Roland Gruntzig Dr. Gruntzig (a German Cardiologist) was cynically received when he first pitched the idea of balloon angioplasty in the American Heart Association annual meet. Dr King, a renowned catheterization specialist at the time said dismissively, “It’ll never work.”45 Dr. Gruntzig, however was persistent on his idea and despite everyone telling him that his idea was going to fail, he remained undeterred. It was only a year later in 1977, when he presented his first four angioplasty cases in humans, that the entire audience in the meet rose to applaud his work. Robin Warren and Dr. Barry Marshall Dr. Warren (Pathologist) and Dr. Marshall (Microbiologist) are both Nobel laureates from Australia who found out that stomach ulcers were caused by bacteria.46Even by 1980s, medical community was stagnant in their beliefs regarding the etiology of stomach ulcers. Years of experience and knowledge led them to believe that stomach ulcers were caused by stress or spicy food.47To some, the idea that the ulcers were caused by a bacterium was absurd. While the other doctors in the medical community argued that no bacteria could live in the acidic environment of the stomach. To prove himself right Barry ingested the bacterial culture and developed ulcers himself.48He then took the antibiotics and got cured. Marshall and Warren won a Nobel Prize in 2005 for their discovery.49 They also developed the 14-C Urea Breath Test for detection of Helicobacter pylori in patients with peptic ulcer disease.46 Jeremy Griffith His work on the “Human Condition” and his theory that teleology is the underlying order in nature, met with criticism from prevalent journals at the time.50 Now, however, teleology is being increasingly accepted. With many federal and private multi-million-dollar initiatives now in place, the area is a prospect in the domain of psychology in the current day. James Allison The Nobel laureate was initially met with skeptic denials when he presented his idea targeting the immune system in cancer management. At that time, immune system was not considered a major role player in cancer and because of which his novel idea and pioneering research could not catch immediate attention of the scientific community. Now, however, drugs based on his initial ideas are set to become the most successful cancer drugs on the market.51 Dr Allison’s work was recognized and he received a Nobel Prize for his contributions in 2018. HOW CAN WE PROTECT OURSELVES FROM SEMMELWEIS REFLEX? Evidence suggests that 21% of papers are rejected without review and approximately 40% are rejected after peer review according to American Journal Experts. This data suggests that around 1/4th of the articles are dismissed and the reason for the dismissal is either the research itself or the writing and presentation of the paper.52,53 In this extract we are focusing on the former. If your research is being refuted for merely the content or ideologies, then you may have become a victim of ‘Semmelweis reflex’. The theory that explains this bias, stems from the tendency to hold on to one’s
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initial belief even after receiving new information that contradicts or disconfirms the basis of that belief. This phenomenon is known as Belief Perseverance.54 Correlation and Causation: The theory of illusionary correlation here comes into play. This is phenomenon of perceiving a relationship between variables even when no such relationship exists e.g. in case of Semmelweis’s opposition, a part of the argument was that doctors were considered to be knowledgeable and respected.55 Medical fraternity simply refused to believe that they could in fact spread infection when in reality there is no correlation between professional stature and sterility or asepsis. Another example would be that of a perceived relationship between skin color or nationality or origin and professional competence which may have been a contributory factor in the opposition faced by African immigrant Dr. Bennet Omalu.56By means of this article we would also like to further this so that experts today are not blind to the blatant similarities between themselves and 16th century scholars who wouldn’t look through Galileo’s telescope and 19th century doctors who refused to wash their hands. Another way to look at this is a common mistake on the parts of researchers to assume that just because we find a correlation between two variables, one causes the other. This is often described in statistical parlance as “Correlation does not imply causation”.57 Clear Impact: When the editor of a journal starts reading the submitted article, they look for a message to be delivered. Always make sure that while writing the article, you must not sway from the reason the study was done and what impact it has on the present-day understanding. Also, one must clearly state the reason for the study in the abstract only so as when people read it further, they should reason along with. The text should not be ambiguous making the reader decipher it in their own understanding. Critically analyze your study yourself: Critically evaluate your own study and findings. Know the implications of what you are hypothesizing. Keep in mind the age-old beliefs and also established ethical standards. Make sure that if you are going against a proven and widely accepted theory, you do so not in a very exclusive fashion, rather give some credibility to it. Although it is indeed true that there is no easy, non-threatening, safe way to contradict established norms especially when they are based on fears, prejudices and self-serving deceptions. Hence be bold enough to come up with your statement. Critically analyze your own study and findings. Talk to people with opposing views and try to answer their questions. Another method is to imagine or explain how the opposite belief might be true. This de-biasing technique is known as counter explanation. It will help you to make sound conclusions rather than jumping to assumptions. Personal involvement: Be personally involved in the process. It is often argued that Semmelweis’s hypothesis was poorly understood by the medical community at that time because he did not personally publish his data until much after his dismissal from Vienna General Hospital.58 Most of the information on his studies came from his colleagues and students.59 Journal Selection: Sandesh and Wahrekar concluded of the 24 factors considered for journal selection, the most important ones being Journal indexing, online submission, impact factor, peer review and publication fees.60 Once the study is complete and the manuscript is ready, it should be submitted in a journal which relates with the article. Authors should pay careful attention to the contributions that their manuscript is making to the pre-existing literature. A broader content matter may be considered relevant for journals that cater to such audiences and vice versa. As Carroll-Johnson (2001) noted, “Choosing the wrong journal can result in outright rejection or, worse, rejection only after a lengthy peer review process that reveals the paper is just not suitable.”61 Another important consideration in journal selection is the impact factor of the journal. One should not get tempted to submit a manuscript in a journal with high impact factor but
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should also see the suitability of the research for the journal.62 Impact factor depends on the number of readers associated with the journal. However, a journal with high readership would likely only accept practice-changing research that would impact a broader audience. With a carefully thought out study design and rigorous quality control measures in place, a high-quality manuscript may be considered for submission to a relevant journal with high readership. Social Media as an outlet: Sometimes you may also face what is known as a publication bias in which the journal authorities may have some subjective reasons to refuse your paper. Whatever may be the reason, in this era of artificial intelligence and cloud computing other means like Social Media and Mass Media are rapid ways to get the word out to the common man. More importantly future research would benefit from cross-media, cross-time and cross-country comparisons on the use of media in social movements.63 Knowing your Limitations: Above all, the tale of Ignaz Semmelweis shows us the significance of having faith in your discovery and standing by it despite resistance. It is easy to become arrogant when you feel like you know more than your peers but understand that your knowledge can’t do much good until it is understood, accepted and instituted widely. Often the road to triumph and acceptance is a long and gruesome one; as the great physicist Stephan Hawking quotes in his proclaimed book, A Brief History of Time: “A scientific truth doesn’t triumph by convincing its opponents and making them see the light but rather because its opponents eventually die and a new generation grows up that is familiar with it.” 64 Exercising caution: Although scientific work that is rejected only to be later accepted needs careful assortment, it is of utmost importance that authenticity and credibility of this work be validated through rigorous review and discussion. Semmelweis reflex does cause delays in acceptance of relevant scientific result, but it also protects us from accepting apparently impactful work that may not be of public good. Certain examples of research works that were initially though to be impactful and practice changing only to be later found that those claims were misplaced are: recombinant factor VIIa, pancreatic resections for nesidioblastosis, anal fistula management by using fistula plugs and extracranial to intracranial bypass arterial anastomosis to reduce stroke. 65 Frontal lobotomy for medicine-refractory-schizophrenia and thalidomide are examples of research works that were later found to be harmful instead.66,67 Summary: Semmelweis reflex is, in fact, an age-old prejudice. It is an inherent human tendency and there is no paucity of historic anecdotes that embody this phenomenon. We have highlighted key elements that prove monumental in the realization of true potential of a new idea, while still exercising necessary caution. With careful and thorough analysis of available literature, we have identified certain steps that when instituted may help in protecting oneself from being a victim of this reflex. A patient, calm, innovative yet intuitive approach is required to make it through the initial friction that any new idea has to face. Perseverance in exercising scientific rigor and meticulous study design are quintessential for an idea to reach fruition. Exercising utmost caution with perception, interpretation, critical self-analysis, the choice of journal and knowing one’s own limitations are few of the many highlighted cornerstones in this review. Science is a sanctum of innovation and discovery. For any new thought, there emerge numerous unanswered questions, many of them being critical and rightfully so, but it is the scientist who must never lose sight of the direction of that original thought, as it may just be the next big leap in science that changes the fate of humanity.
No conflict of interests
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[ILLUSTRATION 1: Yearly puerperal fever mortality rates for birth giving women at Vienna General Hospital’ maternity clinic for the period 1784-1848 reported by Semmelweis.2]
13.000%
11.375%
9.750%
8.125%
6.500%
4.875%
3.250%
1.625%
0.000% 1784
1788
1792
1796
1800
1804
1808
1812
1816
1820
1824
1828
1832
1836
1840
1844
1848
Hand-washing introduced
20%
First Clinic Second Clinic
15%
10%
5%
0% 1833 1835 1837 1839 1841 1843 1845 1847 1849 1851 1853 1855 1857 Hand-washing introduced [ILLUSTRATION 2: Puerperal fever mortality rates for birth giving women at the first and second clinic at Vienna General Hospital 1833-1858 reported by Semmelweis.2]
Dr Vipin K Gupta: Conceptualization, Methodology, Data curation, Resources, writing original draft, Writing-review and editing, visualization, supervision, Project administration Dr Chhavi Saini: Conceptualization, Methodology, Data curation, Resources, writing original draft, Writing-review and editing, visualization Dr Gagan Kalra: Conceptualization, Methodology, Data curation, Resources, writing original draft, Writing-review and editing, visualization Dr Meher Oberoi: Conceptualization, methodology, Data curation, Resources, Writing original draft Dr Md I Nasir: Data curation, Resources, writing original draft, writing-review and editing, visualization Dr Soumya Gupta: Resources, writing original draft, writing review and editing, visualization
No abbreviations were used.