This simple graphic explains ~4 decades of RCT failure and reversed guidelines for harm in critical care. @CritCareReviews @MarionKCampbell @yudapearl

The “guideline vs personalized medicine” debate at #SCCM2024 sidesteps the real PRO–CON question. The primary issue facing the science issue isn’t personalization, it’s whether the present method critical care syndrome guideline derivation itself is valid. Specifically why has transport from guessed, cause-agnostic, threshold-based, triage-gated RCTs produced so much public harm? And is this even mathematically defensible? Will those questions be raised or debated openly? Unlikely. Instead, expect a “synthetic debate”: a superficial exchange that avoids questioning the underlying scientific methods themselves.

Here you see scientists mocking @DrJBhattacharya’s call for combined cutting edge research and reproducibility. Let’s look at the actual history: •~80+ RCTs of corticosteroids in sepsis since the 1970s, using multiple changing consensus entry criteria (SIRS → SIRS+ → SOFA) •~18 RCTs of corticosteroids in ARDS, across several different ARDS definitions. •~15 RCTs of corticosteroids in community-acquired pneumonia, often mixing influenza and non-influenza etiologies. •0 adequately powered RCTs of corticosteroids in pure influenza pneumonia (because influenza was routinely lumped into CAP). And on top of this: •Dozens of meta-analyses, roughly 20–30 in sepsis, 10+ in ARDS, and 10+ in CAP. re-pooling heterogeneous trials built on shifting synthetic-syndrome definitions. What followed? •Polarity-switching guidelines. •Strong recommendations based on pooled averages from causally heterogeneous cohorts. •Silence on influenza in CAP guidelines Now that REMAP-CAP steroid arms were halted for harm, this could force yet another round of meta-analysis and guideline revision. This is five decades of “RCT → meta-analysis → guideline → reversal.” It’s printing money. No deep introspection. No deep failure-mode analysis. But loud criticism when the NIH Director asks for more than “RCT, rinse, repeat.” How is a young investigator supposed to innovate in a science monopoly where indoctrinated consensus panels next guess the latest synthetic-syndrome thresholds that determine funding eligibility? All of this harmful failure with NO causal modeling. Everything taught by @yudapearl and colleagues left on the bookshelf. When a field of clinical science protests this loudly and mocks a leader calling for reform, it usually means the critique is landing and the ongoing patient harm has not been mitigated.