Courage Under Fire


While the title of this column is “Clinical Matters,” you the readers have allowed me to indulge my whims on more than one occasion, often transgressing into matters of the heart. Because this column does not constitute a peer-reviewed journal article and because I feel the two areas, clinical and emotional, cannot entirely be separated, I have the luxury to drift onto the road less traveled blending the two in the hopes of striking a chord or creating an impression not soon forgotten. While peer-reviewed journals have their important place in scientific study, I feel in our small profession, we place too much faith in and too much attention on the peer-review process and assign far too little importance on opinion pieces.

“Blasphemy! Peer-reviewed journals are the cornerstone of the scientific community. Columns and op-eds do not hold a candle to peer-reviewed science,” you shout.

Please consider this: Peer review is not and never will be proof that a study is correct, or even likely to be correct. Erroneous conclusions have been published in peer-reviewed journals in countless numbers.

The editor of the British medical journal The Lancet, Richard Horton, stated: “The mistake, of course, is to have thought that peer review was any more than a crude means of discovering the acceptability — not the validity — of a new finding. Editors and scientists alike insist on the pivotal importance of peer review. We portray peer review to the public as a quasi-sacred process that helps to make science our most objective truth teller. But we know that the system of peer review is biased, unjust, unaccountable, incomplete, easily fixed, often insulting, usually ignorant, occasionally foolish and frequently wrong.”

And, of significant importance in such a small field as ours, is the fact that reviewers tend to be especially critical of conclusions that contradict their own views and lenient towards those that accord with them.

Keep faith

The purpose of this information is not to destroy our faith in peer-reviewed journals, but rather to de-emphasize their stature as irrefutable, and to recognize the important contributions made by non-peer-reviewed articles.

Why? Well let’s take the featured topic of this month’s O&P Business News: Heroes. How could I possibly pull your heartstrings about the heroes all around us and in our daily lives with an abstract, introduction, method, conclusion and discussion, among others? And herein lies the significance of those articles that are not peer-reviewed. It is often found in their goal, their direction and their intention. Speaking for myself, I can say simply this. My goal is to impact your soul, to affect you and yours for years to come in a positive way. Let us not disregard the notion that hearts and minds are nourished, cared for and repeatedly ignited into action by written words created in an informal manner, about an informal topic. Let us not devalue clinical opinions rendered by the well-meaning and their contribution to revolutionizing medicine, or incidentally, for any profession. Let us continue to appreciate the peer-reviewed article, but let us recognize there is an equally if not more important role to be played by other written works.

Power to persevere

We all have our own opinions as to what defines heroism. Courage under fire comes to mind. The important point here is that “fire” can be defined in countless ways, and in our profession we should note that one does not have to “act” as much as persevere. Think about it, our patients have either lost something very dear to them, or had it impacted in such a severe way they needed our help. Very often it is so they can simply help themselves in order not to be a burden on others, especially their loved ones. Now that is a big fire to deal with. Feelings of limited self-worth, feelings of impacting those they love in detrimental ways. I can only imagine the self-deprecation and depression they must experience from time to time and the courage they have to keep it all within. This is quiet heroism, and it so frequently goes unsung. If this were a peer-reviewed journal, I would not be able to sing about it.

Every single time you work with a patient remember this: there is a fire burning within them that is intent on consuming them, though you may not know it. Every day they step up to the fire line and do battle. While some must battle raging forest fires, others do battle in the brush, but all are heroes, quietly, on their own time and in their own way. Please do not forget this as the hero you are working with grimaces and says “it hurts,” or “it is not working for me.” Bite your lip, suck it up and remember who you are dealing with. Long after I retire from this profession, I will salute the heroes I have encountered in my life, and those about whom I have been told. For the rest of my life I will be thankful for having been given the opportunity to serve these heroes. I will always cherish them and the clarity they have brought me, clarity about what is truly important, why we must face the challenges we do, and the men and women that are made, every day, because
of it.

Heroes ensure our world is a kinder, better place to be. I am grateful for being able to not only watch heroes do their thing, but to also in some small way contribute to their lives, to cheer them on, if only briefly and from the sidelines. And even though you will not be able to find these words in a list of peer-reviewed article searches 20 years from now, I hope the point of what I’m saying strikes home, and lasts a lifetime.

For more information:

  • Medical Journal of Australia. 2000;172:148-149.
Randall Alley, BSc, CP, FAAOP, CFT

Randall Alley, BSc, CP, FAAOP, CFT is chief executive officer of biodesigns inc. He is chair of the CAD/CAM Society of the American Academy of Orthotists and Prosthetists, an international consultant and lecturer, and a member of the O&P Business News Practitioner Advisory Council. Alley can be e-mailed at

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